When Does a Change in Health Require a New Swallowing Assessment?
A new swallowing assessment may be appropriate when a change in a person’s health affects—or could reasonably affect—their ability to eat, drink or manage saliva and medication.
Changes following a stroke, respiratory illness, surgery or hospital admission are common reasons to seek advice. New coughing during meals, reduced intake, unexplained weight loss or increased difficulty following a mealtime plan may also indicate that a review is needed.
No single sign confirms dysphagia. The person’s overall health, symptoms, preferences and circumstances must be considered.
Why might swallowing change?
Swallowing is a complex activity that relies on coordination between the brain, muscles, breathing and sensory systems.
A person’s swallowing may change because of:
a new illness or medical condition
progression of an existing condition
changes in strength, alertness or coordination
respiratory or neurological changes
pain, discomfort or dental problems
medication effects
reduced mobility or physical deconditioning
changes in cognition or communication
surgery or medical treatment
changes in the person’s environment or available support
The impact varies from person to person. A health change that has little effect on one person may significantly affect another person’s eating and drinking.
Health changes that may justify reassessment
Consider seeking advice from a speech pathologist following:
a stroke or other new neurological event
progression of a neurological condition
a respiratory illness or significant change in breathing
surgery involving the head, neck, brain, chest or airway
an extended hospital admission
intubation or a period of mechanical ventilation
a marked reduction in strength or physical function
a significant change in alertness or cognition
new or worsening dental or oral health problems
medication changes associated with altered alertness, dry mouth or muscle function
repeated chest infections or respiratory concerns
unexplained weight loss, dehydration or reduced food and fluid intake
These circumstances do not automatically mean that the person has developed dysphagia. They indicate that swallowing may need to be considered as part of the person’s broader health review.
Changes during meals that should be reported
A new assessment or review may also be appropriate when carers, family members or staff notice changes such as:
coughing, throat-clearing or choking during or after eating and drinking
a wet, gurgly or changed voice during or after meals
increased effort, distress or breathlessness while eating
difficulty starting a swallow
food remaining in the mouth
difficulty chewing or managing particular textures
food or drink spilling from the mouth
meals taking considerably longer than usual
increasing fatigue during meals
refusing foods or drinks that were previously accepted
reduced food or fluid intake
difficulty managing saliva
a noticeable change in eating or drinking ability
increased support or prompting being required at meals
difficulty taking medication
These observations can have more than one possible cause and do not diagnose dysphagia. Record what happened and seek advice rather than independently changing the person’s food, drinks or level of assistance.
Some people may also experience swallowing difficulties without obvious coughing. Concerns should therefore be considered alongside the person’s overall health, intake, respiratory status and mealtime presentation.
Why an old swallowing plan may no longer fit
A swallowing assessment reflects the person’s abilities, health, environment and goals at a particular point in time.
Over time, the person’s:
strength and coordination
breathing
alertness
cognition and communication
mobility and positioning
dentition
medication
eating and drinking preferences
available assistance
health priorities and goals
may change.
A reassessment considers whether the person’s current recommendations still reflect their needs and preferences. It does not automatically mean that more restrictions will be introduced.
The outcome may be to confirm the current plan, clarify unclear instructions, recommend different support strategies or identify the need for further assessment.
What if the person appears to be improving?
Improvement can also be a reason to request a swallowing review.
A person may recover strength, alertness or function after an illness, stroke, surgery or hospital admission. Their current texture-modified diet or other mealtime recommendations may have been introduced during an earlier stage of their recovery.
Carers and staff should not independently trial a less-modified food texture, thinner drinks or reduced supervision. A speech pathologist can review the person’s current swallowing and determine whether changes should be considered.
Reassessment is not only about responding to deterioration. It can also help ensure that recommendations do not remain more restrictive than necessary.
What information should be included in a referral?
Clear information helps the speech pathologist understand what has changed and how urgently the person may need to be seen.
Include:
what has changed
when the change began
whether it occurred suddenly or gradually
foods, drinks or situations associated with the concern
how often the signs occur
any recent illness, diagnosis, surgery or hospital admission
relevant medication changes
the person’s current food texture and drink thickness
current assistance, positioning and supervision requirements
any changes in appetite, weight, hydration or respiratory health
the person’s concerns, preferences and goals
observations from carers, family members and staff
a copy of the current swallowing or mealtime management plan
Use specific descriptions. For example, “coughed three times while drinking water at lunch” is more helpful than “did not swallow well”.
What should carers and staff do while awaiting assessment?
Follow the person’s current swallowing recommendations and your organisation’s escalation procedure unless a responsible health professional advises otherwise.
While waiting:
Record specific observations, including what happened and in what context.
Make sure the current plan is available to the people supporting the person.
Follow documented food, drink, positioning, assistance and supervision requirements.
Communicate concerns to the appropriate manager and healthcare professionals.
Monitor for further changes according to the person’s care arrangements.
Seek more urgent advice if the person’s condition deteriorates.
Do not independently change the person’s food texture, drink thickness, medication method, supervision or swallowing strategies based on general information.
When is urgent medical help needed?
A routine swallowing appointment is not a substitute for emergency medical care.
Seek urgent medical assistance if the person experiences:
acute breathing difficulty
severe choking or airway obstruction
sudden severe distress
a sudden neurological change
reduced responsiveness
another medical emergency
Follow emergency procedures and the directions of emergency or medical professionals.
A significant but non-emergency change in swallowing still requires timely clinical review.
What happens during a swallowing reassessment?
A speech pathologist will gather information about the person’s current health, swallowing concerns, goals and mealtime environment.
Depending on the person’s needs, the assessment may involve:
discussing changes with the person and their supporters
reviewing relevant medical and swallowing history
examining oral movement and function
observing eating and drinking
considering positioning, assistance and communication
reviewing the current mealtime recommendations
determining whether further assessment is required
A clinical swallowing assessment and an instrumental swallowing assessment are not the same.
An instrumental assessment uses specialised equipment to provide additional information about swallowing. Examples include a videofluoroscopic swallowing study or fibreoptic endoscopic evaluation of swallowing. The speech pathologist will consider whether this type of assessment is appropriate and likely to provide useful information.
Frequently asked questions
Does every illness require a new swallowing assessment?
No. Consider the nature and severity of the illness and whether the person’s swallowing, breathing, alertness or intake has changed. Seek clinical advice when you are unsure or when concerns persist.
What if coughing only happens occasionally?
Intermittent signs can still be relevant. Record what the person was eating or drinking, their position, the time of day, fatigue and any other circumstances. Share this information with the appropriate health professional.
Can the existing plan be followed while waiting?
Continue following the current plan unless a responsible clinician or emergency service advises otherwise. Escalate concerns according to the person’s care arrangements and organisational procedures.
Will reassessment always result in thickened drinks?
No. Recommendations depend on the assessment findings, the person’s circumstances and their goals. A review may confirm, change or clarify the current plan. Thickened drinks are not an automatic outcome of reassessment.
Does improvement mean the current plan can be changed?
Improvement may justify reassessment, but carers and staff should not independently change the person’s food, drinks or level of support. A speech pathologist can determine whether updated recommendations are appropriate.
Who decides whether an instrumental assessment is needed?
A speech pathologist considers whether a clinical assessment provides enough information or whether an instrumental assessment may help answer important questions about the person’s swallowing.
What to do next
Request a swallowing assessment when a person’s health, eating, drinking or mealtime presentation has changed and their current recommendations may no longer reflect their needs.
Swallowing & Dysphagia Support provides swallowing assessments and mealtime management reviews for people experiencing swallowing difficulties.
Contact Swallowing & Dysphagia Support to discuss the change and determine the most appropriate next step.
Important information
This article provides general education. It cannot diagnose dysphagia or determine an individual’s food texture, drink thickness, suitability for oral intake, treatment, supervision or level of risk.
Do not change an individual’s swallowing recommendations based on this article. Recommendations require individual assessment and should be reviewed when the person’s health, swallowing, goals or circumstances change.
About the author
Written for Swallowing & Dysphagia Support and reviewed by Vanessa Chan, Speech Pathologist.
