Hard to Swallow: When Seniors Experience Chronic Choking

Swallowing Problems in the Elderly

For those with chronic swallowing and choking problems, mealtime can be a source of anxiety and dread, rather than a time of enjoyment. So much of our pleasure in life comes from eating as well as the socializing that surrounds meal time. Having a swallowing disorder changes that; it can be extremely frustrating to have to put so much thought into what one is eating, as well as having to live with the fear that accompanies frequent choking episodes. Choking issues not only affect the person with the disorder but those around them. As family or professional caregivers, one of the scariest things we can witness is our loved one or patient choking on food, medications, or even beverages. Choking can quickly become life-threatening and can cause further complications such as esophageal tears and aspiration pneumonia (a lung infection as the result of a foreign body entering the lungs). It can be both terrifying and embarrassing for the person choking. If your loved one lives in a shared housing environment such as assisted living or memory care, there can be ethical issues as well as you'll see in the story below.

The Ethical Concerns of Chronic Choking

In one of the assisted living communities where I worked in as a manager, we had housing for residents who had advanced care needs. Mr. Keske lived on this high-need floor, and though he could walk with a walker and feed himself, he needed help with all other areas of his personal care. As part of his advancing dementia, he began to lose the ability to speak, though he could answer some questions on some days, and could nod yes or no to simple questions. Along with his ability to talk, Mr. Keske lost the muscle tone in his esophagus, and he began to choke on his food. The choking became a daily occurrence. There came a point when he could not clear his throat on his own, and the staff had to occasionally perform the Heimlich Maneuver on him. We held care meetings with the care staff, our dietary staff, the family members, and we let the doctors know. A pureed diet was ordered for him by the dietician to decrease his chances of choking.

The new diet plan was a relief for staff who had to sit by Mr. Keske for each meal to observe, coach, and intervene if necessary. It was a relief for Mr. Keske's fellow residents who grew tired of having their tablemate choking up food during their peaceful meal times. It was a relief for the doctors and I as we knew he was a candidate for aspiration pneumonia if we did not change his diet. Mr. Keske did not like his food pureed, who would? Ground meat, veggies, and lasagna are not too appealing. But it beat the alternatives. The person who had the hardest time with the new food prep routine was Mr. Keske's daughter Julie. Julie hated seeing her dad with a plate of ground food in front of him. She fought us on this new doctor's order, not caring about the daily Heimlich treatment that had been necessary or her father's loss of dignity when he choked up his meal in front of his peers. Nor did she care about the health risks that Mr. Keske's chronic choking could create.

Julie attempted to have her dad placed on hospice and thought that this would solve the problem. “My dad can eat what he wants because he's going on hospice!” she would tell me. But we, the care staff and management team, had to sit down with Julie and explain to her that we did not want to take the risk of her father getting aspiration pneumonia, could not continue to do the Heimlich on a daily basis, nor did we want to do anything that would cause him further mealtime embarrassment. We had ethical concerns regarding his dignity, and we had to advocate for his fellow residents who no longer wished to witness his choking. We also did not agree to isolating him in his room to eat which was the daughter's second suggestion, as we did not have the staff to manpower this, nor could we support the lack of socializing that would occur with meals being taken alone in his apartment (nor would it solve his swallowing problems). We finally had a breakthrough with Julie, her core issue being acceptance of her father's health decline and dementia progression. Compassion, education, and support were what Julie needed, and Mr. Keske needed pureed food to stay healthy and vital. Dysphagia was a horrible side effect of Mr. Keske's health condition, but when our dietary team worked him, the family, and our caregiving staff, they were able to find many creative solutions. These personalized food-prep solutions allowed Mr. Keske to eat his favorite meals prepared in a safe and appropriate manner, in the dining room with his friends. He remained safe and happy in his home and no longer had to live with the fear and embarrassment that had surrounded his swallowing problems.

Dysphagia and Its Causes

Dysphagia is the fancy medical term for experiencing difficulty when swallowing. Food, even when chewed thoroughly, can get stuck and block, or at a minimum, cause discomfort, as it passes through the esophagus or food can be accidentally inhaled into the trachea which is located right alongside the esophagus (see diagram above). “It has been estimated that as many as 20% of individuals over the age of 50 and most individuals by the age of 80, experience some degree of swallowing difficulty.”¹ We all have trouble from time to time getting a large or dry piece of meat or bread down, but chronic dysphagia can plague the elderly and can cause severe health problems. Why do seniors particularly struggle with dysphagia? A decrease in throat muscle tone is one reason, but below is a comprehensive list of why seniors, in particular, are at risk.

Swallowing function can decrease with age due to the following:

Dental issues: Missing teeth, painful chewing due to dental problems, or poorly fitting dentures or partials can be problematic.
Muscles in the mouth and throat weaken as we age or weakening may be magnified after having a stroke.
A decrease in saliva can affect our ability to swallow. Saliva is needed to correctly and smoothly guide the food from the mouth and throat down the esophagus. Certain medications can also decrease saliva production (known as “dry mouth” in the medication pamphlets and ads).
Neurological disorders such as Parkinson's Disease, Cerebral Palsy, Alzheimer's Disease, or a brain injury can all affect a person's ability to swallow properly.
Having a diagnosis of GERD (acid reflux disorder) can put one at risk as the acid in our stomachs can damage the throat and esophagus after years of having heartburn. Having a diagnosis of Celiac Disease can put you at risk for the same reasons.
Some types of diverticulosis can cause problems as food can get stuck in pockets that exist in the esophagus.
Cancer of the mouth, neck, throat, head, or esophagus can make it difficult to eat safely.
Enlargement of the thyroid, a history of smoking, having neck surgeries in the past, and having osteoarthritis, as well as having boney protrusions or growths (“osteophytes”) in the spinal cord can all put a senior at risk for dysphagia.

“It has been estimated that as many as 20% of individuals over the age of 50 and most individuals by the age of 80, experience some degree of swallowing difficulty.”

Is Coughing the Only Symptom of a Swallowing Problem?

Coughing when eating dry meat is just one of the many symptoms of dysphagia. Seniors will often hide the fact that they are having chronic problems at mealtime out of fear or embarrassment. Sometimes the changes in a person's ability to swallow occur slowly, and the senior can be so used to having issues that they don't notice it or give it much thought. Often it is the family or caretaker of a senior that notices swallowing is becoming more problematic.

If your loved one has swallowing challenges you might notice the following:

Choking or gagging when eating really cold foods such as ice cream or cold/iced drinks.
Thin liquids of any type, even water, trigger a coughing or gagging spell.
They have an excess of thick mucus when they cough up food.
“Gurgly” sounds are present in their throat after eating.
They show fear or apprehension when eating certain foods or when they need to eat in front of others.
They frequently run to the restroom while eating (usually to cough in private).
They exhibit choking signs during a meal and they can't clear their throats or bring up the obstruction. They might then grab their throats, have a panicked look in their eyes, or they might look for, or flag down, help from others. Their face when coughing, may turn red, then blue if oxygen is cut off. If they cannot get any air in, they may stand up in further panic, then pass out from lack of air.

Just because a senior is “used to” having swallowing difficulties and has made certain accommodations to their eating styles to avoid choking on the whole, frequent swallowing events can increase the odds of further complications. It is vital to a senior's health to get advice as soon as a problem is noticed to avoid life-threatening situations from occurring. According to the experts, aspiration pneumonia “is the leading cause of hospitalization and death in nursing home residents.”² and is just one of the many problems that swallowing problems left unchecked, can lead to. Below are some additional problems and risks of chronic swallowing difficulty.

The universal sign for choking. Photo credit: American Heart Association

The Dangers and Risks of not Addressing Swallowing Problems

Choking that leads to passing out or death/ lack of oxygen to the brain
Aspiration pneumonia
Decreased nutritional input, weight loss, and vitamin deficiency
Fear, anxiety, and depression
Decrease in socialization and participating in mealtime if the person is fearful of choking in front of others
Dehydration
Inability to get medications down and digested
Dignity issues and embarrassment

The Heimlich Maneuver . Photo Credit: New York City Health

Common Foods that are Known to Trigger a Coughing or Choking Episode

There are certain foods that are particularly hard to swallow as we age. Seniors will often compensate and adjust a dish that gives them problems by adding gravy or another sauce to it. While this is can be helpful, it is not the answer for everyone, as most gravies and sauces are heavily salted, contain gluten, and can be high in fat content, all of which may be prohibited in some prescribed diet plans. Below is a list of the most common culprits:

Dry beef (steak or shredded beef are the worst) and chicken (usually chicken breast)
Rice or bread products
Raw vegetables, apples, melons
Liquids that are too thin or too cold
Cheese
Hot dogs
Some nuts and seeds, as well as dried fruit
Vitamin capsules or large medication tablets

Steak is one of the most common foods that can trigger a choking episode, particularly in those with swallowing disorders.

Exam and Diagnosis

A physician, registered dietitian, or a speech and language therapist can help determine the exact cause of your senior's swallowing problems. It is best to start with one's primary physician to determine if further testing is needed and to get the necessary referral to see a specialist. The physician will review the senior's medical history, medication list, and symptoms and will then determine the next step. If referred to a speech pathologist or therapist, it is likely that a swallow evaluation and study will be done. If needed, a dental exam may also be recommended.

A senior should see their physician immediately if they develop a swallowing problem, especially if it came on suddenly.

Treatment Options for Dysphagia

A speech-language therapist or pathologist as well a registered dietitian will have many suggestions to help with swallowing problems. A therapist can provide valuable guidance that will decrease one's chance of choking, including the provision of strengthening and retraining exercises. There are adaptive devices, electrical stimulants, and other modalities that can be used, as well as many dietary adaptations that can be made to make swallowing easier and safer. Special diets for severe swallowing concerns, even prescribed on a temporary basis while muscles are being retrained, include a chopped or mechanical diet, pureed foods, or thickened liquids. Patients will also learn behavior modification techniques that will decrease their chances of choking such as slower, more mindful eating, limiting mealtime distractions, and posture improvements. Alternatives to large medication capsules and vitamin supplements such as those in liquid form may be suggested.

Natural treatments for swallowing difficulties include mind-body work, biofeedback, hypnosis, acupuncture, and herbal treatments to ease throat spasms. If therapy and natural treatment options are not effective, medical treatments such as Botox injections or surgery may be discussed and suggested.

Juicing is a phenomenal way to make sure those with swallowing problems get the nutrients they need.
Photo credit: National Foundation of Swallowing Disorders

Caring for Those Who Have Swallowing Problems

To ensure the safety of seniors who have swallowing difficulties, it is imperative that all care providers assisting the senior, as well as any friends and family that might be present while senior is eating, be aware of the problem. Any swallowing-related cueing or environmental suggestions the physician or therapist has instructed on regarding the senior's mealtime should be relayed to care providers.

A food and diet preparation list that contains allowable foods as well as the forbidden ones, should be created and be displayed in a prominent place as well as discussed in person. Besides the consistency of the diet, special attention should be made to ensure that the senior is taking in enough protein and vitamins. Smoothies, protein shakes, yogurt, cottage cheese, scrambled eggs, beans, and homemade soups are fantastic, easy-to-swallow choices that pack a nutritious punch. It is very common for seniors with choking issues to substitute meals with Ensure-type drinks or ice cream, and though they contain some protein and calories, they also contain a high amount of sugar and unhealthy fat. Tofu ice cream or sorbets are much healthier treats!

Care providers should know, and be aware of, the signs and symptoms of a swallowing crisis or choking episode, and all should be trained in the Heimlich Maneuver and CPR.

Advanced directives should be current and immediately available for care staff as well as emergency personnel in the event that a choking episode results in a 911 call. It is also suggested to get an emergency bracelet for the senior to wear that states the person has swallowing issues, and it should be listed on any medication lists. If a senior is sent to the hospital for any reason, the hospital and skilled nursing staff should be made aware of the condition immediately.

Care providers or family members should monitor the senior for any health issues and weight changes, reporting to the physician any concerns.

Finding a related, local support group is suggested both for the senior and their primary caretakers.

Learning CPR could save your loved one's life. Photo: American Red Cross

Quality of Life and Safety Should Always be the Priorities

Having swallowing difficulties can affect a senior's wellbeing both mentally and physically. As I learned while working with Mr. Keske, one's quality of life can greatly be affected when swallowing issues develop and advance. Along with the quality of life, preserving independence and dignity as well as maintaining a senior's ability to make their own food choices, are key elements to focus on when helping a loved one manage this health condition. With proper evaluation, guidance, and some adjustments, most seniors find that they are able to manage their own dietary challenges with minimal disruption and effort. Below are further resources that may be of help- just click on the title to go directly to the websites. As always, please feel free to call us with any questions or for additional resources and support.