RS4270

Geriatric Enabling Occupation: Ageing & Geriatric Practice

Feeding & Swallowing (II) MANAGMENT

Rebecca Wong (OTR)

Adjunct Assistant Professor

Department of Rehabilitation Sciences

The Hong Kong Polytechnic University

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Time Content Intended Learning Outcome (Able to:)

10 min Intro to feeding management Understand the scope

for management

35 min Common conditions with older adults having dysphagia Understand the diversify
& assisting clinical
reasoning for
management
10 min New initiatives in local practice

90 min Various management strategies Understand the use of

different strategies &
develop clinical
reasoning
20 min Remediation strategies

10 min Round up

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Eating & feeding with PEO perspectives for older adults

OP: Swallowing & feeding safely,

effectively, efficiently & satisfactorily by:
Person’s feeding & • Remediation:
swallowing abilities & • Compensation:
difficulties as affected by • Environmental modification/ set up
age change & medical • Diet modification
conditions • Positioning (head & body)…….
• Carer education
• Cueing……
E: • …………
Environment, carer

O: Oral Eating &

feeding
Other form: e.g. tube
feeding

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Oral Feeding Interventions: Treatment & Management strategy
2 perspectives:
• (Treatment) Remediation (skill lab)
• (Management) Compensation / Adaptation (discussed with dementia)

Goals of Remediation: To Improve the capacity for safe feeding by

Improving the condition:
a. Physical: Strengthening, improving ROM & strength…
b. Neuro-motor control: co-ordination & timeliness→ swallow reflex….
c. Alignment: e.g. Beckman techniques ……………

➢ Training outside mealtime (e.g. Vital stim, exercise….)

➢ Training within mealtime (e.g. for generalization, Bodily neglected
patients……) 4

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 Compensation: To modify/ adapt for safe/ efficient/effective feeding by
1. Modify fluid consistency & food texture
a. Food Textures: solid → mechanical soft→ minced → pureed
b. Fluid Consistencies: thin→ thickened (different level of thickness)
c. Modify bolus size, rate of feeding………..
2. Use of assistive device: utensils, seating….
3. (Head/Body) Postures /positioning (before, during & after feeding)
4. Adapt different ways of feeding/eating
• Assistance by feeder, modify rate & amount in each mouthful, sequence of food
presentation, cueing, double swallow, clearing oral cavity…..)
• Level/ ways of assistance (to be discussed in Careful Hand Feeding Program)

5. Modify/ Manipulate the environment to suit the need of the patient (to be
discussed with demented cases)
6. Client & caregiver education: establish a feeding plan (to be discussed in
Careful Hand Feeding Program)
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 Neuromuscular:
stroke
Brain tumours
Progressive conditions:
Alzheimer & dementia disease
Parkinson disease
Multiple sclerosis……….
Medical & Orthopaedic conditions
RA, thyroid
Tumours
End stage of chronic medical conditions
Congested Heart Failure (AHF)
COPD
Aged cerebral palsy & mentally challenged
individuals

COMMON CONDITIONS WITH OLDER ADULTS HAVING

DYSPHAGIA

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Overall (acute + chronic): ~ 25–50-65% of stroke patients
(Depending on diagnostic tools used, setting, timing of
assessment)

DYSPHAGIA ON STROKE PATIENTS

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 Stroke
Unilateral hemispheric stroke Brain stem stroke
– ~42%- 67% within 1st 3 days post stroke
– Recovery for hemispheric stroke, N = 357(Barer,1989) •40% - 75% with poor prognosis
• 30% has problem on 1st day with thin liquid •Severe: absent swallow reflex
• 16% ------------------ 1st week ----------------
• 2% ------------------- 1st month--------------- •Moderate:
• 0.4% ----------------- 6 months ---------------
–reduced laryngeal closure
– Can be a silent aspirator
–If unilateral →ipsilateral pharyngeal
and/or laryngeal muscle paralysis
Common features (not limit to…)
(R) Hemiplegia (L CVA) •Mild:
• contralateral facial & lingeal (tongue) weakness →decreased –affect sensation of the mouth, tongue,
oral co-ordination → slower bolus transportation
• oral apraxia → motor planning for eating, apraxia → motor
and cheek, timing in the trigger of the
planning for self feeding pharyngeal swallow, laryngeal elevation,
• with aphasia & dysarthria [among a study with 50 patients laryngeal closure, and cricopharyngeal
(Mourao, 2016)} relaxation
(L) Hemiplegia (R CVA)
▪ Delayed** swallow reflex/triggering
▪ decreased pharyngeal contraction
•tends to a silent aspirator
▪ More possible aspirator
Basal Ganglia
• cough reflex sensitivity in the elderly with lacunar
infraction in basal ganglia → silent aspirator
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Management specially related to stroke patients (TBD in skill lab)

• Put the food onto the less affected side of the tongue
• Check unilateral food pocketing
– Unilateral pocketing
– tone + sensation, tongue deviation to sound side, unilateral bodily neglect

• Head position when receiving food → relate to closure of 1 side

– approach from middle or non-affected side (if visual neglect, hemianopia present)
– Severe bodily neglected
• Non-affected pharyngeal side being closed as patient turn away from affected side

• Severe apraxia with cueing technique

– Hand over hand (or known as Under Hand) Technique

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• Progressive
• Management with PEO perspective
– compensatory and behavioural strategies
pairs with patient’s remaining abilities
– diet and environmental modifications.

Dementia

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 Dementia: Feeding problems
Visit this Utube video:
(feeding tips) https://youtu.be/tujTZK0s804?si=doJkbHtP2tWj-xco
(General info) https://www.youtube.com/live/AIrjFS3uw9k?si=ylV8-Z-SoWdbOev_

• 85% having feeding problems in last 1.5 • Common among moderately→ late stage demented
yrs before death.
• 6 month mortality rate (after the occurrence • In a study: end stage 24% self-feed themselves, 18% assisted
of dysphagia)= 39% feeding, refuse feeding (26%) or choke on food (32%).
(Mitchell S, NEJM, 2009)
• E.g. prevalence among moderate to severe Alzheimer's (84-93%)
• Neurodegenerative+ Behavioral problem
• VFSS may not be feasible
• Mx: adaptation** + use of available abilities (promote
self feeding, safest), caregiver education**

• General problem: Early → Middle stage of dementia (self feeding)

❖ Decreased sensory awareness (smell sense is last to lost)
❖ Loss of appetite/ change of food preference
❖ Prolonged mealtime

Hong Kong Med J ⎥ Volume 23 Number 3

⎥ June 2017 ⎥ www.hkmj.org

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Middle→ Late/ end stage: Neurodegenerative+ Behavioral problem

Neurodegenerative problem (not limit to) • Alzheimer’s

• Oral phase • Dysphasia, agnosia, apraxia, mood
– Reduce lateral tongue movement for chewing & changes & challenging behaviors as
Tactile agnosia for food in mouth expressed in feeding & swallowing
• Absent to Continuous chewing / food pocketing • Late stage: overchewing/ holding food in
/ multiple swallow→
food (oral apraxia)→ delay in swallow
• →Food refusal / forget to eat / spitting food initiation, pharyngeal difficulty→ food
• → Absent chewing & hold food in mouth refusal
• Frontotemporal dementia
• Delay in pharyngeal triggering → Can be a silent
• Social behavior in mealtime, eat too fast
aspirator (esp when refuse to eat)
• Vascular Multi infarct dementia
• Various problem due to infarct area
• Full Oral motor assessment & training, VFSS,
FESS, …. may not viable
– Management based on direct observation, resources
available, carer attitude…..

Some info from: Hong Kong Med J ⎥ Volume 23 Number 3 ⎥ June 2017 ⎥ www.hkmj.org

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Feeding for mid → late stage demented elderly (teamwork & PEO perspective: Environmental modification + behavioral strategies)
Preparedness before meal~10 min ahead:
• Aim: :Maintain enough nutrition, maintain safe self-feeding
• Catch the brightest time of the day
• Present the most nutritious food 1st → multiple meals (when easily fatigue case)
• Diet modifications: Use of thickened liquid? Pureed vs mechanical soft diet?
Early→ Mid-stage strategy Late-stage strategy
Increase volition/ awareness to eat
• Olfactory stimulation before meal (as last to • Taste last to lost: bitterness, hot & spicy → favourite
lost): food
– to stimulate saliva production, • Use of finger food…… to maintain self-feeding,
– smell from food, a cotton ball with familiar • Most difficult with room temp food
smell (a pouch on bib),
• Increase sensory stimulation:
• Auditory: “today’s plate” • Tactile: facilitate salvia secretion & awareness
• present different taste in a week schedule: – electric toothbrush (feel good with vibration)
e.g. sour (Mon)/ Hot spicy (Tue)/ Sweet
(Wed)…… – Use ice → tongue walking (back to front) →
use of ice popsicle
• Rituals: e.g. wash
➢ increase hand before
awareness meal,techniques in assisted feeding (skill lab)
(sensory),
religious rituals

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During mealtime (mainly mid-stage)
– Problem solving approach with PEO for “accurate” management,
management strategies not limited to: – Increase stimulation to cue self-feeding
– Reduce unnecessary stimulation • Dish/bowl different colour from table
• Minimize environmental distraction: • Name each bite (best with familiar voice) (Late
– Turn off TV, soft music to generate appetite? stage)
– Group vs solitary seating
– Seat the person in the same location
– Walk / stroll & eat finger food from
– Reduce need for decision making: caregiver (for agitated patient)….
• serve 1 food at a time (soup/ rice bowl, water),
• offer minimal eating utensils
– Facilitate safe feeding (Mid→ late stage)
• Cueing to eat:
• Positioning: upright with back support, head
• verbal cues & praise→
position, close to table
• (Late → very late stage) Assisted feeding: (skill lab)

• Prompting / Cueing Techniques

• Use finger food, sip soup from a cup
• Backward chaining & hand over hand technique • CAREFUL HAND FEEDING (late →Very late
• Montessori methods stage when safe feeding is still possible)
• Spaced retrieval • Tube feeding

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Feeding for mid → late stage demented elderly (teamwork & PEO perspective)
After Meal
• Emphasis oral care (especially reduce chance for GNER (Gram-negative enteric
rods) bacteria growth orally
• Sit at least 20 min before bedrest
• Serve happy hour food (best with same favourite food), especially push fluid
intake/ nutrition dense fluid
• Weigh weekly

• Regular follow up & Scheduled feeding assessment

• revise management plan according to patient’s condition

• Good communications with caregiver, caregiver empowerment is ****

Some info from: Hong Kong Med J ⎥ Volume 23 Number 3 ⎥ June 2017 ⎥ www.hkmj.org

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 Parkinsonism (prevalence 50%)
Affecting swallowing phases:
1. Oral phase
• Drooling
• (Resting) Tongue tremor: Repetitive A-P rolling, pumping
– → impaired co-ordination & timeliness →
• Bolus formation: Piece-meal deglutition
• Bolus control: Pre-mature spillage
• Bolus transit:
• Slow oral initiation & transit
• Regurgitate from tongue base onto mouth
2. Pharyngeal phase
• Co-ordination breathing & swallowing may be impaired → aspiration
• Reduce pharyngeal contraction → P residue
3. Esophageal phase
• reduce esophageal peristalsis Similar presentation with chronic Schizophrenia (as with prolonged use of Benzodiazopine 22.7%)
– → positioning at upright (not slugging)
✓ Tends to be silent aspirator especially at end stage →look for gurgly voice after swallow

• Progress to Careful Hand Feeding/ non-oral feeding means

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Parkinsonism (management with different stages, skill lab)
Early stage
• Normal swallowing with no observable changes: monitor weight & patient/ career education
Early impairment
▪ May have difficulty in bolus formation even though other motor problem well controlled with medication
▪ Oral phase: repetitive tongue rolling: MX
▪ Bring swallow under voluntary control
▪ Thickened liquid?, pureed food → Food with good bolus →place in posterior tongue to get 1 good push
▪ Preventive ROM, lip resistant exercise (e.g. use of chewing gum x2 X 5-10 min daily), vocal cord adduction
exercise…………
Moderate impairment
• Diet modification: (skill lab under diet modification)
• Fatigue: >15 min, mx: frequent small nutritious meals
• Delay swallow initiation
– Mx: Increase sensory input (cool food)
• Reduced pharyngeal contraction (skill lab under diet modification)
• Feeding aids:
Late stage (when tube feeding is inevitable)
– Combine tube feeding with pleasure eating

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Example of Medical conditions…………
Congestive Heart Failure
– E.g. Compression of esophagus → affecting esophageal peristalsis
Respiratory problem (e.g. COPD): e.g. swallow-respiratory co-ordination problem
(inhale& hold→swallow→ exhale), reduce cough strength, p contraction…: when..
– Respiratory rate higher than 30/min (N=16-20/min)
– Vital capacity 1500ml or less……
RA (although mainly affecting extremity joints)
▪ Dry mouth (20%)
▪ Painful TMJ joint → affect chewing
▪ Rheumatic involvement of larynx & oesophagus
Cervical Osteophyte
▪ Affect pharyngeal contraction: More difficult with thicker MX: rotating to one side

Alcoholism + thyroid disorder

• Loss sensation in oral cavity → loss of judgement how much to handle in 1 swallow → choking
episodes
• Long term effect of ETOH → toxic effect in cerebellum → oral motor: loss of sensation, ataxia

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Medical conditions
Tumors
Neck/ throat/ tongue
– Surgical scarring:
• Tongue base→ hyoid excursion, pharyngeal contraction, food pocketing in pharynx
Nasopharyngeal carcinoma: compressed cranial nerves
Acoustic neuroma: compromise swallowing center in brain stem
Metastasis to brain: depends on location …………

• End stage of chronic medical conditions

– Congested Heart Failure (AHF)
– COPD

• Aged cerebral palsy & mentally challenged individuals

• Frailty: muscle loss
• Traumatic Brain Injury (TBI): depends on location…

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Careful Hand Feeding
Comfort Feeding
(for advanced stage dementia, end of life)

NEW INITIATIVES ON LOCAL PRACTICE

Acknowledgement: Part of the information is from Dr Bobby Ng
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Careful Hand Feeding as an alternative… for
Care of Patients at End of Life Stage

插唔插喉

Hong Kong Med J ⎥ Volume 23

** I strongly advise you to review the supplementary video “【杏林
在線】鼻胃喉的需要性”. In it, DR. AU-YEUNG, a renounced Number 3 ⎥ June 2017 ⎥
Geriatrician from TMH shared a comprehensive review ** www.hkmj.org

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 Careful Hand Feeding (CHF) vs tube feeding for advanced demented
AS INTERDISCIPLINARY RISK MANAGEMENT PROTOCOL FOR
FEEDING PROBLEMS IN SEVERELY FRAIL ELDERS WITH
ADVANCED NEURODEGENERATIVE DISEASES

N=764 with advanced dementia (Comorbidity: CVA,

DM, kidney disease….),
mean age=89, 74% residential,
dysphagia (50%), behavioral feeding problem (33%),
both (17%).
No difference on 1-yr survival rate between
Tube feeding vs CHF.
In another related publication of same group:
also finds that patients on CHF has 40% lower
risk of pneumonia than those with tube feeding

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TEAM WORK
• Patient & family, caregiver…..
• Doctor
• With nurse, speech therapist,
PT……
• With other team members

• To build/ maintain a strong

team in delivering service to
people with eating and
feeding dysfunction, especially
with Careful Hand Feeding
Program

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DIRECTION FOR FURTHER ADVANCEMENT
• Journal:
• Journals Dysphagia
• Course
– HKOTA
– FEED

Journals & books

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Food & Liquid modification (consistency, texture, size, rate of feeding)
Assistive device
Posture/ head positioning
Feeder & Careful Hand Feeding Program
Feeding Plan
Remedial strategies

SKILL LAB II

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A Local Sample of Instruction for Feeding Patients with Swallowing
Problems, Prepared by Speech Therapist Colleagues

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A Local Sample of Instruction for Feeding Patients with Swallowing Problems, Prepared by Speech
Therapist Colleagues

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A Local Sample of Instruction for Feeding Patients with Swallowing Problems,
Prepared by Speech Therapist Colleagues

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Management:
Reduce the risk of aspiration by modify: diet

• Diet modification (food consistency) : use of

– thickened liquid & pureed food
• Bolus formation & control in oral phase: easier for forming bolus & gather the
bolus before swallow (bolus cohesiveness)
• Bolus control in pharyngeal phase: slower rate of the liquid (viscosity)
running down, so less is gathered in pyriform sinuses.

– semi-solid food:
• bolus control for ligneal co-ordination problem
– Cold / hot vs food at room temperature
– Carbonated thin liquid may reduce aspiration in neurogenic dysphagia
– Careful with mix of texture

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Management:
Reduce the risk of aspiration by modify: bolus size, rate of feeding

• Amount (bolus size):

– 3-5 ml (1 teaspoonful) as safe measure when
food is pooled (stored) in vallaculae before
swallow is triggered (delayed swallow reflex
triggering), thus reducing the risk of aspiration
– 1 maximum mouthful of food ~ 21ml (heap in
tablespoon)
– BUT amount of nutrition intake & dehydration
may be an issue if using teaspoon

• Rate of feeding (by the feeder)

– For those with compulsive eating
– Time to allow second (dry) swallow (before another
spoonful of food/ liquid)

• To clear pharyngeal residue

– By observing & feel, (skill lab: listening
with cervical auscultation)

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Principle for determining fluid consistency & food texture
Different consistency level

DIFFERENT CONSISTENCIES & TEXTURES

Acknowledgement: Part of the information is from Dr Bobby Ng

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 Two local popular thickeners

Note:
1. Thickener lead to persistent feeling a full stomach → client may defer the needs for more
fluid.
2. Taste is plain → may not be motivated to take adequate amount of thickened liquid → risk
of dehydration
3. Water would be separated from thickened liquid if it is left unattended for sometime, or
when stored in mouth

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International Dysphagia Diet Standardisation Initiative (IDDSI)
7 levels of fluid & food
https://iddsi.org/Framework (accessed on 28-Oct-2021)

正餐餐 (Normal)

軟餐 (Soft) Select the right

equipment 10 ml
syringe for level 1-3
碎餐 (Minced) level liquid

糊餐 (Pureed) 特杰流質(Extremely Thick)

(例如：薯蓉)

流質餐 (Fluid) 中杰流質(Moderately Thick)

(例如：果蓉、沙律醬、奶昔)

少杰流質 (Mildly Thick)

(例如：杰芝麻糊/合桃露、乳酪)

微杰流質 (Slightly Thick)

(例如：粥水、蕃茄汁、忌廉湯)

稀流質 (Thin)
(例如：清水)

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 Skill Lab: Fluid Consistency 濃稠度 How to Prepare according to different brands of
thickened powder
稀流質 (Thin)（例如：清水） -
微杰流質 (Slightly Thick)（Ready made example: 粥水、蕃茄汁、忌廉湯） e.g. 100 ml水+ 2茶匙凝固粉
少杰流質 (Mildly Thick / Nectar)（例如：杰芝麻糊/合桃露、乳酪） 100 ml水+ 3茶匙凝固粉

中杰流質(Moderately Thick / Honey)（例如：果蓉、沙律醬、奶昔） 100 ml水+ 4茶匙凝固粉

特杰流質(Extremely Thick / Pudding)（例如：薯蓉） 100 ml水+ 5茶匙凝固粉

• A group of 2 students, create 100ml of mildly thick liquid & moderately thick liquid each (cup, water,
thickener, 10ml syringe, stop watch)
• perform IDDSI test with 10ml of liquids to define level of IDDSI

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Level 4: Pureed, IDDSI Testing Methods
Extremely Thick

Standard of pureed food

1. Eaten with a spoon but possible to use a fork
2. Cannot be sucked through a straw; Does not require chewing
3. Falls off the spoon in a single shape; holds shape on plate
4. No lumps, not sticky
5. Liquid MUST not separate from solid
6. Functionality: Poor tongue control; no need for biting or chewing; can be used with missing
teeth or poorly fitting dentures
7. Testing:
• Fork test – press a fork into the substance and the time marks remain, no lumps;
• Spoon tilt test – food should slide off a spoon, in a cohesive unit, when the spoon is
tilted with no stickiness and very little residue on the spoon
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(Solid) Food Texture
Food Texture How to Prepare Indications 適用長者
種類 製作預備
正餐餐 正常烹飪方法 沒有咀嚼或吞嘸困難
Nil chewing or swallowing problems and can
(Normal)
tolerate all types of food texture

軟餐 將正常餐炆稔、煮 適合咀嚼有困難，要求少量咀嚼

(Soft) 稔、燉熟 the meal is prepared for the person who has some
difficulties with chewing

碎餐 將食物切碎或攪碎 適合咀嚼或吞咽有困難的長者，若舌頭活動不良，
可加入獻汁，製成濕潤的碎餐
(Minced) All food are minced into small particles so that
minimal chewing is required. Please note that the
small bits, if dry, may be very difficult for those with
impaired tongue movement to manipulate into a
cohesive bolus. A moist minced diet is
recommended under these conditions.

糊餐 將食物攪拌至幼滑 無需咀嚼，只須少量舌頭活動控制吞咽。

(Pureed) 糊狀 All foods are blenderized to attain a smooth

pureed texture. The consistency requires NO
chewing, NO additional moisture and unless too
thin, very little tongue manipulation

流質餐(管喂) 現成營養配方奶品 吞咽有困難，容易引發吸入性肺炎，或不能單靠用

口進食來攝取足養料及水份
Fluid (Tube ／粥水 For patients with marked dysphagia, repeated
Feeding) incidences of aspiration pneumonia, weak medical
conditions, or whose daily intake cannot be solely
relied on oral mode.

Pre Prepared food 現成的糊類

•Locally prepared
•Imported
https://eshop.culturehomes.com.hk
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Considerations in the Choice of a Suitable
Regular Food for bolus formation & control
Ideal Food Bolus for Patients with Swallowing Problems

Texture 性 質 Function 作 用 Examples 例 子

Composed of fine particles Compensate for decrease in strengthen Congee with pureed meat
由幼細粒子形成的 of chewing X congee with diced meat
Moist 潮濕的 Compensate for limited saliva secretion Pudding, egg custard, soften pumpkin/ squash,
補充不充分的唾液 X biscuit/ egg roll
Cohesive (sticking together) Improve sensation and compensate for Pudding, egg custard
內聚的 weak tongue movements 增強感覺，補
救無力的舌頭運動，亦減少脫落和殘留物
Examples of Problematic solid food

Types 種 類 Examples 例 子
Too hard 太硬 Candy 糖果, nuts

Too dry & crispy – easily broken into pieces太乾、易碎 Biscuit 餅乾, egg roll
Too sticky 太黏稠 Sticky rice, peanut butter, banana, bread 糯米飯、花生醬、香蕉
、白麵包
Too large in size 太大 Fish ball 魚球、燒賣
Slippery onto pharynx 潤滑的 Rice dumpling 湯圓…..soft banana…
Various textures mixed together Noodle with thin sauce, Congee with diced meat 肉碎粥, fruit with
不同質感 seeds

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Also need to consider Medication intake
• Liaise with doctor /pharmacist / nurse to consider the use
of (According to the recommended texture/
consistency)
– appropriate type of the drug, e.g. pill vs. syrup.
– large pill can be cut into small pieces/crushed into fine
particles, but not changing the property of the drug
– Thickener can be added to syrup without changing its
property.

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 Principle for determining food texture, consider:
Ability in bolus formation & control abilities:
Thickened Liquid with high viscosity Pureed food as a cohesive bolus
(Level I→ III)
To tackle Problem Rationale To tackle Problem Rationale
Pre-mature due to poor easier to Decreased due to poor denture pureed food easier to form
spillage tongue base & keep chewing bolus without chewing
soft palate bolus in
approximation mouth due to decreased oral pureed food easier to form
motor strength bolus without chewing
(unilateral /bilateral) + bolus check especially
with decreased tone on sulci
Delay due to may slow Decrease chewing initiation Pureed food for bypassing
pharyngeal decreased down the e.g. decreased oral sensitivity in oral phase?
triggering sensitivity of flow onto demented.
swallow reflex & in the e.g. tongue resting tremor in
pharynx Parkinson's disease
BUT
▪ Soft diet vs pureed diet (for demented cases)
▪ Caution with mixed texture food******
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Principle for determining food texture in pharyngeal phase, consider:

Thickened Liquid Food

To tackle Problem Rationale Rationale
Incomplete epiglottic closure Easier to form Moist food easier to form bolus
cohesive bolus &
slow down the flow
in pharynx

Pharyngeal residue due to poor P Thin liquid may be Avoid sticky food
contraction more preferrable.
Avoid liquid with
Pharyngeal residue due to poor high viscosity (e.g.
UE opening assess suitability of
level III & IV liquid)

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Possible Feeding utensils……
Raised rim to
scoop food

syringe

straw

R Wong 2023 BScOT Geri 41

 Management:
Reduce the risk of aspiration by modify: bolus size, rate of feeding
• Amount (bolus size): (Refer to slides on later part)
– Liquids (thin & thickened):
• 3-5 ml (1 teaspoonful) as safe measure when food is
pooled (stored) in vallaculae before swallow is triggered
(delayed swallow reflex triggering), thus reducing the risk
of aspiration
– Food
• (minced/ soft/solid) optimum 1 mouthful of food ~ 21ml
– Cautious with problem of dehydration & malnutrition
• Skill lab: use of teaspoon & tablespoon for optimal volume of swallowing
• Rate of feeding
– Some may need a second (dry) swallow before another
spoonful of food/ liquid
• To clear pharyngeal residue
• By observing & feel, (listening with cervical auscultation)

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 Management strategy: Head positioning (Adapting to different
ways of feeding/eating)

Chin Head tilt

down Head turn

1. Chin down (Head down)

2. Head rotated to the affected / either side
3. Head tilt
4. Head back/ tilt

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 Management strategy: Head positioning
Chin down (Head down): most common
– Purpose:
1. Generally: helps easier hyoid elevation for more
efficient swallow
2. For delayed swallow triggering (pharyngeal
phase)→ (Purpose) widen valleculae to capture
fluid/ food before swallow triggering,thus
prevent bolus entering into airway
– Space 3-5ml…………..

– Consider:
• Feeder position****
• Drinking with a cup vs cut-out cup
– cut-out cup may prevent neck extension when clearing
last fluid content at the base of the cup
– Use a cup with board opening

R Wong 2023 BScOT Geri 44

Management strategy: Head positioning (Head rotation & head tilting)
• Head rotated to the affected side for CVA cases
▪ For unilateral pharyngeal weakness ( with pharyngeal residue on the affected side of pharyngeal wall)
→ (Purpose) eliminate affected side from bolus path

Presentation
of spoon

Last
slide

• Head rotated to either side (for general cases)

– For residue in pyriform sinuses due to upper esophageal sphincter poor opening→
• Set the hyoid bone away from pharyngeal wall (open side) so UE sphincter can be relaxed easier

• Head tilt to R or L
– For those with unilateral oral & pharyngeal residue
– → Use of gravity to guide food/fluid flow, e.g. head towards sound side in CVA cases
• Likely combine with the use of thickened liquid
• Presentation of spoon
• To the non-affected in unilateral stroke with tongue deviation, decreased sensation/
unilateral (bodily) neglect
R Wong 2023 BScOT Geri 45
 Adapt to different ways of feeding/eating
Effortful swallow ……. & others
• Purpose:
– To improve tongue base retraction & residue in valleculae
– (can be an strengthening exercise: discuss later)
• For:
– Patients who have residue in valleculae
• Technique:
– ask patient to squeeze very hard throughout the swallow.
• Excess effort should be clearly visible in the neck during the swallow.
• Can be a strengthening exercise if patient practice in dry swallow

Check oral
residue

(Cue to) “Cough” to

Dry/ second clear
swallow: pharyngeal
residue
To clear Prevent reflux, min 20 min
pharyngeal
residue
R Wong 2023 BScOT Geri 46
Sitting / body postures

Side lying: hold residual bolus on

pharyngeal wall instead of
allowing it to drop into the
airway (but no strong proof)

Sitting upright
Follow principles for seating:
• pelvic position in maintaining upright…, neutral alignment, symmetrical & even
weight bearing
• UL on table…..
• Close to table…..

Keep upright >60° 20 min after meal to

prevent reflux

R Wong 2023 BScOT Geri 47

Adapt to different ways of feeding/eating: Feeder

• Self feed vs Feeding with feeder (Total assist [Facilitate safe bolus
formation] →Cueing → hands on supervision [monitoring self feeding]
– *however, in demented case, swallowing *may be easier to manage with self-
feeding (especially some chewing is needed to be maintained)
• Feeder’s position: sit in front of the person, eye contact can be made at
or slightly below the person’s eye level
a) ***Enables the patient to maintain their chin in the neutral to chin down
position
b) Promotes social interaction between the person and feeder (can be a
distraction for demented cases).
c) Allows the feeder to monitor the patient’s swallowing by *observing
laryngeal elevation.
d) Avoid putting the food too far at the back of the tongue → induce gag
reflex

e) Do not cover patient’s mouth in case of coughing

f) Caution/ protection of feeder on food spitting/ spillage/coughing

R Wong 2023 BScOT Geri 48

Adapt to different ways of feeding/eating
Rate & amount in each mouthful, sequence of food presentation,
• Amount (bolus size):
– 3-5 ml (1 teaspoonful) as safe amount when liquid/ food is
pooled (stored) in vallaculae before swallow is triggered
(delayed swallow reflex triggering), thus reducing the risk
of aspiration
– 1 optimum mouthful of food ~ 21ml
– plastic- / silicone- coated spoon
– However, demented cases may need a larger bolus than
5ml to increase the awareness (*cohesiveness)
• ate of feeding
– Feeder observe/ palpate /listening with cervical auscultation
swallowing action before introducing another spoonful
– Some may need a second (dry) swallow before another
spoonful of food/ liquid
• To clear pharyngeal residue • The RiJe Cup is the assistive drinking device that
works with thin and nectar-thick liquids IDDSI
• By observing & feel, listen Levels 0, 1 and 2.
• Sequence of food presentation • Automatically dispenses a set amount (3 to
– ? Alternate liquid with food? 15ml) of thin and nectar-thickened liquids to
promote safe small swallows.
– High calorie food 1st?

• RiJe® Cup - RiJe Cup - Home Page

R Wong 2023 BScOT Geri 49

Management strategy: Cueing
( total assisted feeding aiming at increasing nutrition intake]
Usually, thickened liquid & pureed food are used
1. If patient does not open mouth to receive the food (aware of tongue thrust):
❑ physically open mouth technique
a. Apply light pressure to lips open mouth,
b. Head down position→ Apply pressure with middle finger hold the chin

2. If patient holds a mouthful of food & does not initiate chewing:

1. Press with the (padded) spoon onto the front of the tongue in order to increase awareness, (hot/cold food)
2. Assist chewing technique
3. (stroke to induce saliva)

3. If patient holds a mouthful of food & does not initiate swallowing:

❑ stroke neck to facilitate hyoid elevation

4. Bypassing oral phase***careful

❑ position food to posterior part of tongue to bypass oral phase

R Wong 2023 BScOT Geri 50

Prompting / Cueing Techniques
Assisted feeding (with feeder with cognitive/ apraxia problem) aiming at self feeding
1. Backward chaining: Feed first few bites to “prime” self-feeding behaviour → then hand
the spoon to patient (may need hand over hand technique)
2. Press with the spoon lightly onto the front of the tongue in order to increase awareness→
position food to post part of the tongue
3. Montessori methods and spaced retrieval
4. Hand over hand technique

R Wong 2023 BScOT Geri 51

 Adapt to different ways of feeding/eating : Mouth care
• Purpose:
– Eliminate the possibility of
1. Gram-negative and anaerobic pathogens (Clinical Interventions in Aging 2016:11 189–208)
2. Food residue
• from mouth entering the lung due to aspiration (especially elderly in LTC)

• Immediately following a meal, clear with a toothette (or finger wrapped with a
disinfected gauze & distilled water).

• Food residue due to:

⮚Weakened tongue and cheek muscles unable to form a cohesive bolus of food →
food residue end up lodged in various sucli
⮚Weakened oral sensation unable to detect food particles lodged →not attempt to
remove.
⮚ If a person is able to sense the residue, limited range of tongue movement may prevent efficient
clearing. (as well cognitive ability)
⮚Insufficient saliva production may contribute to poor bolus formation tends more
residue + more difficult to gather & remove oral residue

R Wong 2023 BScOT Geri 52

An example of Oral Care protocol (to reduces Pneumonia in Older Patients)

Oral Care Intervention

• 5 minutes of tooth brushing

after every meal +
• professional hygiene weekly.
• When considered necessary,
the regimen was complemented
by povidone iodine swabbing.
• removal of dentures at bedtime

R Wong 2023 BScOT Geri 53

 Reference: (please read the pdf file for more info)
https://www.healthyhkec.org/healthcare/geriatrics/09.pdf
Careful Hand Feeding
(for advanced stage dementia, end of life)

LOCAL PRACTICE
Acknowledgement: Part of the information is from Dr Bobby Ng

R Wong 2023 BScOT Geri 54

CAREFUL HAND FEEDING
PROGRAM
AS INTERDISCIPLINARY RISK
MANAGEMENT PROTOCOL FOR
FEEDING PROBLEMS IN SEVERELY
FRAIL ELDERS WITH ADVANCED
NEURODEGENERATIVE DISEASES

Comfort Feeding
• Comfort-oriented (least invasive)
• Quantity not main focus
• Taste favourite foods
• Risk of aspiration

Source:
https://www.hkag.org/EOL/pdf/23%20Aug%202019%20Ms%20S
abrina%20Ho%20talk%20on%20Comfort%20feeding%20and%2
0Careful%20hand%20feeding.pdf
Hong Kong Med J ⎥ Volume 23 Number 3
⎥ June 2017 ⎥ www.hkmj.org
R Wong 2023 BScOT Geri 55
EIGHT Standards for Low-Risk Feeding (Oral Feeding)
• Feeding standards are adopted from :
• EIGHT Standard Procedures
for feeder (developing a feeding plan & feeder education)

1. Reviewing feeding
“Facilitating Effective Eating in Recommendations
Dysphagia” (FEED) Program 2. Positioning for Oral Intake
3. Food Check (consistency)
• A Self-Directed Learning Program
4. Feeder Position
for Feeding Assistant 5. Amount & Rate
6. Clearing the Oral Cavity
7. Post Meal Position
8. Documentation

The older version “St.

Peter’s – A
Self-Directed Program for
Feeding Certification” (with
Chinese Translation & contributions by
local OTs)

Or a newer version “Facilitating Effective Eating in Dysphagia” (FEED) Program at

http://mohawkcollege.ca.libguides.com/ld.php?content_id=34006200

R Wong 2023 BScOT Geri 56

 A Standard need to be follow & monitored to ensure
Required Level of Assistance safety and quality

界別 用餐時間 員工：弱老
Level of Assistance Required Meal Time Staff : Elderly ratio

I - 監督 每日3餐，每餐 30 分鐘 1:10
Supervised

II - 輔助 每日3餐，每餐 30 分鐘 1:4
Assisted

III - 餵食 * 每日3餐，每餐 20 分鐘 1*:1

Careful Hand Feeding

IV - 餵食（加餐）* 於正常3餐時間外加多1至2餐，每餐 20 分鐘 1*:1

Careful Hand Feeding (additional
meal)
V - 管喂 於正餐時間外進行，每日6餐 1*:1
Tubing Feeding

*員工需接受餵食技巧訓練 Involved staff would required training in “Low Risk Feeding” procedures

R Wong 2023 BScOT Geri 57

 Feeding Documentation: Feeding Instruction
• GOAL: Provide the key information for team communication

• Prior to any oral intake of food or fluids, all feeding

recommendations should be read and subsequently followed.
• The information may include the following:
a) required assistance level
b) required diet (food & fluid) *** food allergy
c) general feeding instructions
d) positioning instructions (for both the person and feeder)
e) rate of feeding
f) quantity per mouthful
g) person-specific feeding tips
h) preferred emergency procedure(s) – in case of choking
a) Abdominal thrust
b) Tracheal suctioning
c) Gravity assisted drainage……..
d) Know where to call for help (is the related team member)….

R Wong 2023 BScOT Geri 58

 Documentation (after meal)

•GOAL:
–Track changes
– communication with team member
•Should contain info as in a logbook:
–type of liquid & food taken
–quantity of food and fluids taken
–Any unusual (or significant) incidents occur during a meal: e.g.
coughing, spillage, energy level,
–Any action taken
–Who is the feeder
–………

R Wong 2023 BScOT Geri 59

Preferred Emergency Procedures in Case of Choking
1. The Abdominal Thrust 腹部壓擠法
▪ This procedure (formerly known as the Heimlich manoeuvre) simulates
the effects of coughing. It consists of a series of abdominal thrusts,
creating an internal pressure that has the potential to force a solid mass
固體食物 up and out of the airway. The procedure is less effective in
ejecting semi-fluid masses such as pureed foods and thickened fluids.
2. Gravity-Assisted Drainage Procedure 地心吸力引流法
▪ For pureed and semi-solid food 糊狀或半固體食物
3. Tracheal Suctioning 利用抽吸機 (only by qualified personnel, e.g. Nurse,
Physiotherapist …)
▪ can remove semi-fluid blockages from below the level of the larynx
• Cautions
a) Prompt Emergency Call especially for severe signs of asphyxia (i.e., acute
distress and rapid cyanosis) 進行急救程式，嚴重者應立即送院醫治
b) Be aware of those patients / family who opt for DNAR (Do NOT Attempt
Resuscitation)
R Wong 2023 BScOT Geri 60
 Goals of Remediation: To Improve the capacity for safe
feeding by
Improving the condition:
Physical: Strengthening, improving ROM
Neuro-motor control: co-ordination & timeliness swallow
reflex….
Alignment: e.g. Beckman techniques ……………

Training outside mealtime (e.g. Vital stim, exercise….)

Training within mealtime (e.g. for generalization, Bodily
neglected patients……)

INTERVENTIONS: TREATMENT

R Wong 2023 BScOT Geri 61

 Remedial (Int J of Stroke, 2016: 11(4), 399-411)

Improving neuro-motor control:

1. Strengthening & re-conditioning:
– Oral motor exercises (can be used in oral feeding, e.g. effortful swallow)
– Oral / lingual exercise: ROM/ strengthening/ co-ordination

2. Tactile-thermal stimulation: to improve sensitivity of swallow reflex

3. Neuro muscular electrical stimulation: Vital-stim, E-Stim

4. Alignment: Beckman’s Techniques

5. Transcranial magnetic stimulation & transcranial direct current stimulation: cortical

stimulation with principle of neuroplasticity/ cortical re-organisation

6. Acupuncture

7. Surgery: UE sphincter dilation, myotomy

R Wong 2023 BScOT Geri 62

Oral motor Exercise: Vocal cord adduction exercises
• Purpose: to increase the ability in closing the vocal cords (as the last gate) & the
strength of pharyngeal contraction in order to prevent food and/or liquid from entering
the airway.
• For: risk/ evidence of aspiration, coughing
• example of the exercises:
– pulling up on the seat of a chair with both hands + prolonging “ah” for 5-10 sec X 3
X5-10 times daily.
– Sign of improvement: stronger & clearer “ah”

• Caution: Many exercises involve isometric contraction of neck/UL. Caution must be taken
with patients with uncontrolled high blood pressure/ poor cardiac conditions as bearing
down/ holding breath may raise blood pressure. Also for patients with poor pulmonary
conditions/ end of life stage.

R Wong 2023 BScOT Geri 63

 Oral motor Exercise: Effortful Swallow & Supraglottic Swallow
Effortful Swallow
• Purpose: To increase tongue base retraction and pressure during the pharyngeal
phase, thus reduce the amount of food residue in the valleculae.
• For: with pharyngeal residue in the valleculae after the swallow.
• How: While dry swallowing (or during meal on each mouthful), squeeze very hard
(that this excess effort is clearly visible in the neck).
– For exercise: Repeat this up to 10 times in 1 session X 3 sessions daily

Supraglottic Swallow
• Purpose: to improve epiglottic closure before swallow & clear of residue after swallow
• For: patient with delayed/ reduced epiglottic closure, delayed pharyngeal contraction,
poor oral control of liquid & pre-mature spillage onto pharynx.
• How: Take a deep breath and hold it→ Keep holding your breath while you swallow→
Cough immediately after swallowing.
source: https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/swallowing-exercises-closure-of-the-larynx-exercises

• Swallow exercise by OT: https://napacenter.org/swallow-strengthening-exercises/

R Wong 2023 BScOT Geri 64
Oral motor Exercise: Shaker Exercise

• Purpose:
– To increase laryngeal elevation + “pull-open” UE sphincter by strengthening
upward and forward movement of the hyolaryngeal

• For: with pharyngeal residue due to poor UE sphincter opening

• How to Perform:
– few sec → 1 min head lifts (not holding breath) in the supine position (high
enough to be able to observe their toes without raising their shoulders). 1-min
rest between lifts. X30 X 3-6 daily
Logemann, Jeri A. et al. A Randomized Study Comparing the Shaker Exercise with Traditional Therapy: A Preliminary Study. Dysphagia. 2009
December; 24(4): 403–411.

R Wong 2023 BScOT Geri 65

 Local practice: e-stim
Beckman Oral Motor
Intervention

Vital Stim

R Wong 2023 BScOT Geri 66

EMST (expiratory muscle strength training)
(Clinical Interventions in Aging 2012:7 287–298)

• Purpose:
– Strengthening (muscles are important for breathing
out forcefully, coughing, and swallowing) & improve
expiratory pressures for better airway protection
– How: The muscles are exercised by blowing into
the device until you generate enough pressure to
open the spring-loaded valve

R Wong 2023 BScOT Geri 67

ROUND UP

R Wong 2023 BScOT Geri 68

 Round up: Swallowing revisit:
The physiological process with the following functions for effective, efficient &
safe swallowing (why & how): timeliness, co-ordination, neuro control…..
1. Preparation of the bolus effectively (range & strength, co-ordination
of……..)
– Bolus formation & control (problems are cause by….)

2. Transportation of the bolus effectively, efficiently & safely (range &

strength, co-ordination/ timeliness
• Tongue base & hyoid bone excursion, & nasopharyngeal closure,
jaw & lip closure
• Posterior pharyngeal wall contraction, epiglottis closure
– Esophagus peristalsis

3. Protection of airway from bolus misdirection safely (range & strength, co-
ordination/ timeliness)
– Risk of aspiration

4. Based on your understanding on above in providing assessment &

recommending various intervention

R Wong 2023 BScOT Geri 69

ROUND UP
1. Understand common clinical picture &
management for various conditions
• Dementia: * of environmental
modification/adaptations
2. Management strategies contributing to
safe/efficient/effective feeding
1. Be pragmatic
2. Based on clinical reasoning
3. Combining:
• Use of different liquid
consistencies/ food textures: e.g. Poor tongue base
control
Poor pharyngeal
triggering
Incomplete
epiglottic closure
Food residue I Food residue II

why & how

Fluid consistency Thickened liquid If thicken liquid is required Combine head rotate with
• Positioning techniques: why & with other problem, balance thicken
with “thinner” thickened liquid
how to reduce being stuck as
• Assistive devices: why & how residue

• Possible ways of feeding……..: Food texture pureed

why & how
Modify bolus size/ 5ml liquid Allow time for double
3. Some remediation techniques rate of feeding swallow (with feeder)
4. Understand: Careful Hand Feeding/
Comfort Feeding so that we can be a Assistive device Teaspoon for 5
contributive team member ml

Head positioning Chin down Head rotate

Different way of Supraglottic Effortful swallow Supraglottic swallow

feeding/ swallow Double swallow Double swallow
maneuver Vocal cord adduction Shaker exercise
exercise

R Wong 2023 BScOT Geri 70