Elderly choking on food is a significant problem as the 4th leading cause of death in long term care! The risk of elderly choking on food increases as they age due to muscle loss and disease progression. So what can we do to reduce the risks while maintaining quality of life?
Learn how to develop a safe nutrition care plan to reduce choking in the elderly without eliminating foods helps maintain quality of life. The issue is balancing safety, facility risk, and residents right to choose. It’s a fine line we have to walk but we can be the solution!
You can also scroll to the bottom to find the NEW Frequently Asked Questions section!
Elderly Choking on Food
Choking is 8 times more likely to happen in older adults than any other age groups.
Choking on food was the 4th leading cause of death in long term care 1 !
Is there a way to manage quality of life and respecting food choices with safety while swallowing?
Yes!
There are ways that can safely manage an older adults risk of choking on food and water.
This does not mean that all the foods a person loves needs to be eliminated, but it does mean alterations. This issue needs to be looked at from a quality of life aspect, there is no need to eliminate all foods.
The first solution we see is changing to a mechanically altered diet to reduce choking risk. But this severely limits food choices1. In older adults the focus should be on liberalizing diets as much as possible while managing the safety of foods.
If you want to read about safely liberalizing diets in the elderly, read this article which walks you step by step on how to accomplish it!
There are tools available that can be used to check if a person has difficulty swallowing, also called Dysphagia. If you want a free copy of a meal observation screen which can help spot Dysphagia, click here.
Dysphagia is a common issue in the elderly due to weakened throat muscles and complicated medical histories that contribute.
Some common diagnoses that are associated with Dysphagia are:
Throat, Head or Neck Cancers
Dementia
Alzheimer’s disease
Parkinson’s Disease
Stroke
Advanced Age
If anyone has these diagnoses, they should be checked for Dysphagia as they are considered at higher risk for it. But we don’t just want to monitor for trouble with food, we also want to monitor for swallowing difficulty with fluids as well.
Elderly Choking on Water
Choking on water is a huge sign that there is difficulty swallowing. A person will not necessarily be at risk of choking to death on water, but there are adverse health consequences of choking on water.
Choking on water or any other fluids increases the risk of aspiration pneumonia. The top risk factors for choking on water leading to aspiration pneumonia are:
Deterioration of swallowing
Dementia
Suctioning
Dehydration
If you notice any of the following signs and symptoms when a person is drinking water, they may be having aspiration:
Coughing constantly during and after drinking
Clearing their throat after drinking
Wet sounding voice after drinking
Spilling water out of their mouth while drinking
Eyes watering while drinking
All of these are signs of Dysphagia. Obviously it doesn’t necessarily just have to be water, it can be any type of thin fluids.
How Can We Reduce Elderly Choking on Food?
Reducing the risk of elderly choking on food and fluids is a two-phase approach. You need to control what you can with the patient specifically, and you need to adjust the food and fluids.
Patient Specific Adjustments
Any person who is a risk of Dysphagia or has had noted swallowing difficulties, you should follow the steps below to help reduce their risk.
Step 1:
Perform an initial nutrition assessment and list any of the diagnoses that put an elderly person at high risk of choking.
You can either find these in their medical chart or through a meal observation, which should be performed upon admission (Note: You will need to do both! Review their medical chart and perform a meal observation).
These conditions put an elderly person at highly risk of choking on food3:
1. History of Stroke/CVA
2. Dry mouth
3. Ill fitting dentures or missing teeth
4. Impulsive eating behaviors (shoveling food in, eating too quickly)
5. Dysphagia, confirmed or suspected
6. Multiple Sclerosis
7. Parkinson’s Disease
8. Dementia, Alzheimer’s, any type of Cognitive Impairment
9. Cancer related to head/neck
Step 2:
Fill out your nutrition assessment, and place your patient on your ‘High Risk Tracking Tool.’
It’s a great way for you to keep track of your patients with different conditions that put them at high risk of nutrition problems.
This tool will help you when you:
Take part on the high risk team in your facility
Prepare you for Standards/Audits of your facility
Keep you up to date with charting on time
Keep you up to date with follow-up
& Give your patient the best care possible!
If your patient has any of the above conditions – they are at an elevated risk for choking, and you will want to assess whether they have Dysphagia.
Step 3:
Perform a meal observation upon admission (think day of, first meal and repeat for 2-3 meals). I personally like to observe a meal myself, it’s important that you know what’s going on and see it for yourself.
If your facility does not have a standardized meal observation form, you can use the one I have posted in the Resources section for free!
A meal observation allows you to assess high risk patterns for elderly choking risk such as:
Elderly choking while eating
Elderly coughing while eating
Elderly pocketing food
Elderly coughing while drinking
and more that can be found in the free meal observation form!
You will also be able to take note of things that other health professions won’t know/understand because YOU are the EXPERT in nutrition. You are evaluating the patient to assess their risk of choking – even if they have no evident diagnoses that would indicate they are high risk.
Step 4:
Review your findings after 2-3 observations.
If you noted that the elderly person had indicators of swallowing difficulty, they are at increased risk for choking on food. Coughing while eating in elderly is a frequent caution that they are at increased risk for choking.
One thing that is not on the meal observation form but you should take note of, what is their pace of eating a meal? If a patient is constantly ‘shovelling’ (for a lack of a better term) food into their mouth without finishing their previous bites, this is an impulsive eating behaviour.
Impulsive eating behaviours can put a patient at a higher risk for choking as well.
There is little that you can do to control this, though having someone sit with them at meals to provide assistance, is a good start.
For a patient like this the assistance would involve: staff sitting with them throughout a meal, you can put another patient at that table that also needs assistance as the ratio is typically 2 residents:1 staff member.
The staff member can place one food item in front of the patient at a time, this will help to slow the pace of the meal. The staff can also:
Offer cueing/reminders to slow down
Ask them questions about the taste and texture of the food
This can offer a great way for the patient to focus more on their food at meals, even if their cognitive level is not fully intact.
After you have completed your meal observation, you can now finish your initial nutrition assessment form. There is an ‘Initial Nutrition Assessment Form’ available if you need a better tool for your workplace.
Ensure in the section where you can leave comments about their meal observation/meal intake (where ever on your forms you can fill in additional findings) that you comment on what YOU have observed and whether they are at an elevated risk for choking. It is important that you have this in writing!
Sample Chart Notes for Elderly Choking Risk
Time to chart on your findings! Read these sample chart notes:
- “RD completed LTC initial nutrition assessment for resident, see RD section of the chart for full report, findings, and nutrition interventions. Consult with RD as needed going forward.”
As you can see, this chart note is short and sweet. Some facilities and RD’s don’t like to rewrite everything that they have found, and in most cases this is okay. You write which section of the chart they can find your report and findings in, so that should be sufficient for some places. But you need to know before writing this type of chart note. - “RD completed LTC initial nutrition assessment, see RD section for full report. In summary: RD suspects patient is at elevated risk for choking at meal times related to impulsive eating behaviour as evidenced by meal observation. See RD section for meal observation report. RD will have staff provide 1:1 mealtime assistance to minimize risk of choking at meal times, staff will provide foods one at a time for patient and explain the food item. RD will complete a quarterly meal time observation screen form to be completed for patient to reassess patients risk for choking risk and make adjustments to care plan as needed going forward. RD is available for consult as needed going forward.”
This type of chart note gives the section of the chart where the report can be found, but also states the problem that was found.
I will typically do this type of chart note if it was a problem that I want staff reading through the chart to be aware of without having to refer to my full report. Again though, check with your facility about the type of chart note that they want you to complete.
If you have found that your resident is at an elevated risk for choking – you need to put this in the care plan! You need to have interventions to go along with it as well.
Sample Nutrition Care Plan for Elderly Choking Risk
Need/Problem (Depending on the phrasing of your first category in MDS)
Resident at increased risk of choking at meal times due to impulsive eating behaviours at meals.
Goals
Resident will have reduced risk of a choking at meals through nutrition interventions at meal times.
Interventions
Resident will have 1:1 staff assistance at meal times.
Resident will be provided with 1 meal item at a time at meals times by staff providing assistance.
As you can see the Problem is met with a goal which will be achieved through the nutrition interventions that you have proposed. You always want to make sure that their care plan is individualized, a staff member who has never met the resident should be able to know exactly how to treat that resident just by reading your care plan.
Need/Problem
Resident is at increased risk for choking due to Dysphagia diagnosis secondary to CVA.
Goals
Resident will have reduced risk of choking at meals through altered diet texture, fluid viscosity and staff monitoring.
Interventions
Resident will be provided with a Standard Long Term Care Diet, Minced Texture, Mildly Thick Fluids.
Resident will be provided with 1:1 assistance at all meals.
Resident will be in a sitting position for 30 minutes after each meal.
So there you have it, part 1 of how to reduce choking risks in your facility! Part 2 will be continued and it will be Menu-Focused ways of preventing choking incidents!
Menu Focused
A menu doesn’t need to be completely overhauled to reduce choking in elderly. You do however want to focus on serving soft foods for elderly. This includes vegetables, meats, fruits, and all. If you want soft snack ideas for elderly, click here.
High Risk Choking Foods for Elderly
You want to alter the following foods for the elderly:
Hot Dogs
Sausages
Grapes
Green Beans
Nuts and Seeds
Raw Carrots
Tough Meats (Roast Beef)
Bone in Meats
Raw Vegetables
You don’t need to completely eliminate these foods because they may be culturally important to a patient. Or it may simply be their favourite foods.
For example, sausages may be a food a Ukrainian patient (My grandfather for instance) has always eaten, completely eliminating it may reduce quality of life.
If you want a free poster to put up in your facility on how to serve foods to reduce elderly choking, check out our Resources section here!
Soft Foods for Elderly
We can alter these foods for the elderly, by serving them in a soft version or altering the presentation. Here’s how you can alter them on your menus without eliminating.
Hot Dogs & Sausages – Slice Down the middle to reduce the circular length that may get stuck in the throat.
Grapes – Served in half.
Green Beans – Chopped in smaller pieces.
Nuts & Seeds – Crushed.
Raw Carrots – Unlikely to serve this way, it’s best to not serve ‘coin shaped’. Serve steamed/cooked so they are softer, and avoid baby carrots due to the size.
Tough Meats – Serve with gravy, cook for longer in moisture to make it more tender.
Bone in Meats – Best to avoid serving bone in meats due to high risk for everyone!
Raw Vegetables – I would only serve this if it is their preference. It is best to serve the vegetables soft and cooked.
Concluding Thoughts – Elderly Choking on Foods
A Dietitian should review a menu very closely to reduce the high risk foods for choking. We are able to alter menus without completely eliminating foods.
The Dietitian should also monitor closely residents that are high risk for a choking incident. Keep these residents on a high risk tracking sheet, and make sure you follow up with at least an annual meal observation screen.
Also don’t forget to check out our Shop section! Lots of fantastic resources made by a Dietitian to help you have the solutions to common nutrition problems faced in LTC at your fingertips! No more digging around the internet!
Frequently Asked Questions
- What if a person doesn’t agree to modifying a diet texture and choose to live at risk?
This is a common issue. Everyone has a right to choose and refuse care, read this article for a step by step guide on how to handle this situation. - Are there ways to safely manage swallowing without modifying a diet texture?
Yes, here are some tips on how to manage Dysphagia:
Sits upright before and after meals for 30 minutes to help digest food
Cueing and reminders to chew and swallow
Adding moisture to dry foods and meats
For more tips, you can read this article on how to manage Dysphagia. - What other resources can I look at to monitor swallowing issues?
A Speech Language Pathologist (SLP) is always a great resource to consult. An SLP is an expert in safe feeding and swallowing, if you suspect someone may be having difficulty swallowing, contact an SLP for a full assessment. - Are there any other contributing factors to Dysphagia?
There are some modifiable factors that may be contributing to difficulty swallowing such as:
Ill fitting dentures
Cognition decline
Poor teeth condition
Certain medications
These are all factors that you can do something about without modifying a diet texture.
