For Caregivers: Swallowing Problems After Stroke

Some people have trouble swallowing (dysphagia) after a stroke. This makes choking more likely. It also puts their health at further risk for conditions like aspiration pneumonia. Aspiration pneumonia is an infection of the lungs that occurs when food or liquid goes into the lungs instead of the stomach. To make sure your loved one gets the nutrition they need, a speech therapist may teach them ways to improve swallowing.

If swallowing is a problem, changes in diet and body positioning may help. Some people are directed to turn the head to a specific side to aid swallowing. Adding thickeners to liquids may also make swallowing easier. Some people need to avoid hot or cold items. Sometimes, eating smaller amounts of food at a slower rate can help. If a person can't take food or drink by mouth, a feeding tube may be needed. As swallowing improves, restrictions will be adjusted.

Many people are helped by exercises. Some exercises strengthen muscles in the mouth for better swallowing. Others improve tongue movement and lip closure. This keeps food in the mouth until the person is ready to swallow.

The speech therapist will teach you which food textures and liquids your loved one can swallow safely. You and the therapist can discuss examples of foods that your loved one enjoys. The International Dysphagia Diet Standardization Initiative (IDDSI) has created a diet plan for people with dysphagia. The dysphagia diet has levels that rate drinks and foods on a thickness scale from 0 to 7.

• Level 0 (thin). These are watery liquids, such as juice, tea, milk, soda, beer, and broth. You can drink them through a straw or nipple, or from a cup.
• Level 1 (slightly thick). These are thicker than water. They require more effort to drink than thinner liquids, but they still flow through a straw or nipple.
• Level 2 (mildly thick). These liquids flow off a spoon but more slowly than thinner drinks. With some effort, they can be sucked through a straw or sipped.
• Level 3 (liquidized, moderately thick). You can drink these from a cup or suck them through a straw with some effort. These are liquids that may be thick enough to be eaten with a spoon. An example is a thick milkshake. Their texture is smooth without lumps.
• Level 4 (pureed, extremely thick). These are usually eaten with a spoon. You can't drink them from a cup. An example is pudding.

• Level 3 (moderately thick). These are foods that:
  • Don't require chewing.
  • Have a smooth texture but are not lumpy.
  • Can be eaten with a spoon, but not with a fork.
  • Are not thick enough to stand stiff on a plate, like molded gelatin.
• Level 4 (pureed, extremely thick). These foods:
  • Can often be eaten with a spoon and sometimes with a fork.
  • Can't be drunk from a cup.
  • Don't need to be chewed.
  • Can be molded, such as gelatin.
  • Aren't sticky or lumpy.
  • Fall off a spoon all together when tilted and still hold shape on a plate, such as pudding.
  • Can't be poured, but move very slowly if the plate is tilted.
• Level 5 (minced, moist). These foods:
  • Can be eaten with a fork or spoon, or with chopsticks if you have good hand control.
  • Can be scooped and shaped on a plate, such as mashed potatoes.
  • Are soft and moist, but don't separate into liquid.
  • May have small lumps that can be mashed with the tongue.
• Level 6 (soft). These foods:
  • Are tender, moist, and bite-sized.
  • Can be eaten with a fork, spoon, or chopsticks, but don't need a knife to cut.
  • Must be chewed.
• Level 7 (regular). These are:
  • Normal, everyday foods of varying textures, including soft, stringy, hard, and crunchy.
  • Foods that can be eaten by any method, such as from a cup or using utensils.
  • Foods that need to be chewed, with all types of textures and may have pieces that can't be swallowed, such as gristle.