British Geriatrics Society
Best Practice Guide
Dysphagia Management for Older People Towards the End of Life
1. Executive Summary
Older patients in acute hospitals frequently have dysphagia, resulting from acute or chronic
illnesses such as stroke, dementia, and respiratory diseases. Dysphagia management
requires a collaborative, multidisciplinary team (MDT) approach. Dysphagia assessment and
management for older people is best provided by the MDT because of the complexities and
inter-related nature of their needs; swallowing cannot be assessed in isolation. Geriatricians
therefore have an important role to play in overseeing the management of dysphagia.
The decision-making process regarding whether to provide an older person with artificial
nutrition and hydration or continue to allow food and drink by mouth once their swallowing
becomes unsafe provokes difficult ethical decisions for professionals and patients. There are
currently wide variations in the management decisions made, and inconsistencies occur in
MDTs working across acute settings in the UK (Groher 1994, Logemann et al 2008). As a
result patients’ are often unable to access the specialist services required to effectively
manage their eating and drinking difficulties towards the end of life; potentially causing more
distress in the longer-term.
Professionals within the MDT need to work together to ensure a comprehensive geriatric
approach is applied in relation to dysphagia management, considering the risks and benefits
of eating and drinking for each individual to enable optimal quality of life. A co-ordinated
approach, particularly towards the end of life is essential for patients with dementia and other
chronic, progressive conditions, to ensure consistent transfer of care between acute and
community settings.
2. Introduction
Ageing does not necessarily cause dysphagia, but the potential for developing dysphagia
becomes increasingly common with advancing age (Leder and Suiter 2009). Age-related
changes affect head and neck anatomy and physiology, increasing the risk of dysphagia.
These include: tongue pressure changes, slower swallowing, increased airway penetration,
sensory changes, and oesophageal motility changes (Ney et al 2009). These changes
contribute to older people being more vulnerable to dysphagia, as a result of a decreased
functional reserve (Robbins et al 2002).
The rising incidence of dysphagia for older people in hospitals, particularly those over 80
years of age (Leder and Suiter 2009) has many health implications including: malnutrition,
dehydration, poor oral hygiene, choking, aspiration pneumonia, and increased need for
institutionalised care (Marik and Kaplan 2003, Ney et al 2009). Complex feeding decisions
regarding the continuation of oral intake or commencement of artificial nutrition for patients
with severe dysphagia are becoming more frequent for Geriatricians, and they in turn seek
advice from their MDT colleagues, such as speech and language therapists and dieticians.
The management of swallowing difficulties for older people towards the end of life remains an
under researched area (Bath et al 2000, Wright et al 2008). Research and guidance has
focused on decision-making for initiating artificial nutrition and hydration for older patients
(Enrione and Chutkan 2007, Volkert et al 2006), but alternative dysphagia management
options such as risk management have yet to be fully evaluated (Dibartolo 2006, Palecek et al
2010). Research is needed to develop the required specialist approach to dysphagia
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management for older people (Leder and Suiter 2009, McCullough et al 2007), especially
those living with progressive chronic conditions who are nearing the end of their life. Bestpractice guidance is available in relation to managing dysphagia for specific conditions
affecting older people; commonly stroke and dementia. (These are referenced and available
below; see section 4.) Specific information regarding feeding and hydration management
towards the end of life is also available in the BGS best practice guide ‘Nutritional advice in
common clinical situations’.
The Royal College of Physicians has provided recent structured advice for oral feeding
difficulties and dilemmas particularly towards the end of life, which are an excellent referent
for MDTs working in this area. It covers in detail: 1) Background: oral feeding; 2) Techniques
of artificial nutrition; 3) Ethics; 4) Law; 5) Practice, and gives just consideration to risk
management and social oral feeding techniques:
“Patients with oral feeding difficulties deserve special care but may not receive it. Their care
should be tailored to their requirements, not to the needs of others. It should, as far as
possible, preserve their oral intake. If this is impossible, tube feeding may be necessary, short
or long term. Very rarely, intravenous nutrition may be appropriate” (RCP, 2010).
3. Definitions/Terminology
Artificial nutrition and hydration – refers to tube feeding by either; Naso-gastric tube (NGT)
or Percutaneous Endoscopic Gastrostomy (PEG).
Aspiration –refers to pulmonary aspiration, the entry of secretions or foreign material into the
trachea and lungs which can lead to aspiration pneumonitis (Logemann 1998).
Dysphagia – refers to oro-pharyngeal dysphagia defined as “difficulty in swallowing or
impairment in the movement of swallowed material from the pharynx to the stomach”
(Logemann 1998). This definition is most commonly used in the literature referring to this
type of dysphagia.
Oral intake – refers to when the main route of feeding and hydration is through the mouth, via
the oesophagus, into the stomach (Logemann et al 2008).
Risk management – describes an approach to dysphagia management where patients
continue to eat and drink, with the support of the multidisciplinary team, despite an ‘unsafe
swallow’ and ongoing risk of aspiration, (RCP 2010). This approach is also referred to
clinically as ‘at risk feeding’ or ‘comfort feeding’.
Swallowing – refers to the entire act of deglutition, the process whereby something is passed
from the mouth to the pharynx, into the oesophagus, and to the stomach, whilst the epiglottis
is shut to prevent material from falling into the airway and causing aspiration (Logemann
1998).
4. Health Policy and Guidance
There are several related policy documents and guidelines which relate to dysphagia
management, particularly towards the end of life:

Dementia: supporting people with dementia and their carers in health and social care.
(2006) National Institute for Health and Clinical Excellence; DOH:
http://publications.nice.org.uk/dementia-cg42

Living well with dementia National Dementia Strategy (2009) DOH: Crown Copyright.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd
Guidance/DH_094058
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
Management of patients with dementia. A national clinical guideline, (2006) Scottish
Intercollegiate Guidelines Network, Edinburgh: http://www.sign.ac.uk/pdf/sign86.pdf

Management of patients with stroke or TIA: Assessment, investigation, immediate
management and secondary prevention (2008) Scottish Intercollegiate Guideline
Network. Edinburgh:http://www.sign.ac.uk/guidelines/fulltext/108/index.html

Management of patients with stroke: identification and management of dysphagia
(2010) Scottish Intercollegiate Guideline Network:
http://www.sign.ac.uk/guidelines/fulltext/119/index.html

Mental Capacity Act (2005), London: HMSO
http://www.legislation.gov.uk/ukpga/2005/9/contents

Nutrition advice in common clinical situations (2009) Good Practice Guides, RJA,
British Geriatrics Society:
http://www.bgs.org.uk/index.php?option=com_content&view=article&id=41:gpgnutritio
n&catid=12:goodpractice&Itemid=106

Nutrition Support in Adults: oral nutrition support, enteral tube feeding and parenteral
nutrition (2006) National Institute for Health and Clinical Excellence; DOH:
http://publications.nice.org.uk/nutrition-support-in-adults-cg32

Quality Standard for end of life care for adults (2011) National Institute for Health and
Clinical Excellence; DOH. http://publications.nice.org.uk/quality-standard-for-end-oflife-care-for-adults-qs13

Royal College of Speech and Language Therapists “Speech and language therapy
provision for people with dementia” (2005) RCSLT Position Paper, RCSLT: London.
http://www.rcslt.org/docs/free-pub/dementia_paper.pdf

Royal College of Physicians (2010) Oral Feeding Difficulties and Dilemmas:
particularly towards the end of life. Royal College of Physicians & British Society of
Gastroenterology, London.
http://bookshop.rcplondon.ac.uk/contents/pub295-ca2ff0c8-85f7-48ee-b8578fed6ccb2ad7.pdf

Stroke: diagnosis and initial management of acute stroke and transient ischaemic
attack (TIA) (2008) National Institute for Health and Clinical Excellence; DOH.
http://publications.nice.org.uk/stroke-cg68

The National Stroke Strategy (2007) DOH: Crown Copyright.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd
Guidance/DH_081062
5. Models of Service Provision
The RCP outlines the following approaches for the MDT to consider in managing dysphagia
towards the end of life:
1.
2.
3.
4.
Full oral feeding using a range of compensatory strategies
A combination of oral and non-oral feeding
Palliative feeding using small amounts of food, mainly for enjoyment
Artificial nutrition using non-oral methods
“Speech and language therapists can advise on strategies to minimise aspiration risk,
facilitate eating and drinking, and improve nutritional status. These are modifications of food
and fluids including changes to texture, consistency and quantity swallowing strategies
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including manoeuvres and sensory techniques; positioning and postural techniques; external
strategies such as carer support, environment and administering food and drink; and
behavioural and cognitive techniques” (RCP, 2010).
Patient capacity and wishes
Patients’ wishes are of primary importance. A competent patient is able to make an informed
decision about whether they wish to continue to eat and drink despite an unsafe swallow. For
those patients who lack capacity the Mental Capacity Act which came into force in 2007 is
followed and the MDT and patient advocate acts in the best interest of each individual patient
(DOH, 2005).
MDT working
Dysphagia management should be patient centred and a team decision made, drawing on all
levels of expertise. A MDT approach to dysphagia management is well established, and
recognised as best practice to optimise nutrition and hydration for patients (Garo et al 2004,
Logemann 1998, Marks and Rainbow 2001). Although the Geriatrician holds the final
responsibility for the decisions regarding a patient’s swallowing and nutritional management,
they should work closely with speech and language therapists and dietitians to optimally
manage dysphagia. Speech and language therapists are able to provide detailed information
about the severity of the dysphagia and recommend how safe a person’s swallow is to
manage food and drink orally, assessing the aspiration risk. Dietitians can recommend how
patients can best meet their nutrition and hydration requirements. Nurses provide daily
hands-on assistance for those patients who have swallowing difficulties and need to be
supported and engaged in the process as part of the MDT. Occupational therapists and
physiotherapists can also help to manage dysphagia, with regards to respiratory
management, positioning, and optimal feeding strategies.
Patient characteristics
The following are an important consideration when deciding on the dysphagia management
approach taken:

Distress – the level of patient distress is an important factor in continuing oral intake.
This can be distress related to:





Respiratory status – this refers to any underlying respiratory disease which may
impact on:





eating and drinking,
artificial nutrition and hydration
feelings of hunger/thirst
repeated hospital admissions/ changes of environment.
safe co-ordination of swallowing
nutrition and hydration requirements
airway protection
swallow comfort
Mobility – this refers to how mobile a patient is which may impact on:





positioning
chest status
feeding dependence
airway protection
swallow comfort
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
Risks – this refers to the different risks to the patient of:





aspiration (of oral intake and/ tube feeding)
being Nil-By-Mouth
oral hygiene
reduced social well being
dehydration and under-nutrition
Medical management
In making dysphagia management decisions towards the end of life it is essential to consider
the following:





Acute/ chronic dysphagia
The underlying medical condition/s (see related Healthcare guidelines for specific
conditions)
Nutritional status
The stage of their condition
The prognosis
Professional training
Specialist training in the needs of older people is essential in order to take a holistic
management approach to dysphagia. Swallowing difficulties cannot be managed in isolation
to other difficulties this patient group may face. Coordinated MDT training in this area for
geriatricians, speech and language therapists, nurses and dietitians is essential to enable all
factors to be taken into account when decisions are made regarding a dysphagia care-plan.
Principles from formal training in palliative medicine concerning end of life care and treatment
decisions may also be applicable.
6. Recommendations






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A holistic patient-centred MDT approach to dysphagia management is essential.
Expertise of speech and language therapists and dietitians should be sought and a
team decision made which is in the best interest for each individual patient.
Specialist experience and training in the needs of older people is essential.
Geriatricians need to work with speech and language therapists and dietitians to
encourage engagement throughout the care of the patient, ensuring continued access
to specialist services to help make swallowing as comfortable and safe as possible
towards the end of life.
Dysphagia management needs to move away from a discipline specific framework in
order to take more risks for the benefit of the whole patient.
There is a need to develop alternative dysphagia management strategies such as
social and hand feeding techniques with a focus on comfort rather than risk, and
outcomes pertaining to quality of life.
Older patients with dysphagia need to have an individual dysphagia care plan
outlining the agreed management approach.
“At the end of life, even if deemed to have an ‘unsafe swallow’ a risk management
approach may offer the patient the best quality of life. If in doubt a trial of nasogastric
feeding with clear agreed objectives may be appropriate. Tube feeding should then
be withdrawn if failing to achieve the objectives. ‘Nil by mouth’ should be a last resort,
not the initial default option” (RCP 2010).
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7. References
BATH, P., BATH, F., & SMITHARD, D. (2000) Interventions for dysphagia in acute stroke.
Cochrane Database Systematic Review.
DIBARTOLO, C, M. (2006) Careful Hand Feeding: a reasonable alternative to PEG
tube placement in individuals with Dementia. Journal of Gerontological Nursing, 26-32.
ENRIONE, E. & CHUTKAN, S. (2007) Preferences of Registered Dieticians and Nurses
Recommending Artificial Nutrition and Hydration for Elderly Patients. Journal of the American
Dietetic Association, 107, 416-421.
GARO, S., MONTORFANI, C., & PICHARD, C. (2004) Dysphagia and nutritional treatment:
decision tree. Rev Med Suisse Romande, 124, 625-628.
GROHER, M. E. (1994) Determination of the risks and benefits of oral feeding. Dysphagia, 9,
233-235.
LEDER, S. B. & SUITER, D. M. (2009) An Epidemiologic Study on Aging and Dysphagia in
the Acute Care Hospitalized Population: 2000-2007. Gerontology, 55, 714-718.
LOGEMANN, J. (1998) Evaluation and Treatment of Swallowing Disorders (rev-ed), Austin,
Texas, Pro-Ed
LOGEMANN, J., RADEMAKER, A., PAULOSKI, B., ANTINOJA, J., ET AL. (2008) What
Information Do Clinicians Use in Recommending Oral versus Nonoral Feeding in
Oropharyngeal Dysphagic Patients? Dysphagia, 23, 378-384.
MARIK, P. E. & KAPLAN, D. (2003) Aspiration Pneumonia and Dysphagia in the Elderly.
Chest, 124, 328-336.
MARKS, L., & RAINBOW, D (2001) Working with Dysphagia, Oxon, UK, Speechmark
Publishing Ltd.
MCCULLOUGH, G. H., ROSENBEK, J. C., WERTZ, R. T., SUITER, D., & MCCOY, S. C.
(2007) Defining Swallowing Function by Age: Promises and Pitfalls of Pigeonholing. Topics in
Geriatric Rehabilitation, 23, 290-307.
NATIONAL INSTITUTE OF CLINICAL EXCELENCE (NICE) (2011) Dementia: supporting
people with dementia and their carers in health and social care. NICE, London.
NEY, D. M., WEISS, J. M., KIND, A. J. H. & ROBBINS, J. (2009) Senescent Swallowing:
Impact, Strategies, and Interventions. Nutr Clin Pract, 24, 395-413.
PALECEK, E. J., TENO, J. M., CASARETT, D. J., HANSON, L. C., ET AL. (2010) Comfort
Feeding Only: A Proposal to Bring Clarity to Decision-Making Regarding Difficulty with Eating
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for Persons with Advanced Dementia. Journal of the American Geriatrics Society, 58, 580584.
ROBBINS, J., LANGMORE, S., HIND, J. & ERLICHMAN, M. (2002) Dysphagia Research in
the 21st Century and Beyond: Proceedings from Dysphagia Experts Meeting, August 21st,
2001. Journal of Rehabilitation Research and Development, 39, 543-548.
ROYAL COLLEGE OF PHYSICIANS (2010) Oral Feeding Difficulties and Dilemmas:
particularly towards the end of life. Royal College of Physicians & British Society of
Gastroenterology, London.
VOLKERT, D., BERNER, Y., BERRY, E., CEDERHOLM, T., ET AL. (2006) ESPEN
Guidelines on Enteral Nutrition: Geriatrics. Clinical Nutrition, 25, 330-360.
WRIGHT, L., COTTER, D., & HICKSON, M. (2008) The effectiveness of targeted feeding
assistance to improve the nutritional intake of elderly dysphagic patients in hospital. Journal of
Human Nutrition and Dietetics, 21, 555-562.
Author: Ella Chakladar on behalf of the British Geriatrics Society (Public Advocacy,
Policy and Communications Committee).
November 2012
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