The scope of this page is swallowing disorders in adults (18+). See the Dysphagia Evidence Map for summaries of the available research on this topic.
Dysphagia is a swallowing disorder involving the oral cavity, pharynx, esophagus, or gastroesophageal junction. Consequences of dysphagia include malnutrition and dehydration, aspiration pneumonia, compromised general health, chronic lung disease, choking, and even death. Adults with dysphagia may also experience disinterest, reduced enjoyment, embarrassment, and/or isolation related to eating or drinking. Dysphagia may increase caregiver costs and burden and may require significant lifestyle alterations for the patient and the patient’s family. Speech-language pathologists (SLPs) are the preferred providers of dysphagia services and are integral members of an interprofessional team to diagnose and manage oral and pharyngeal dysphagia. SLPs also recognize causes and signs/symptoms of esophageal dysphagia and make appropriate referrals for its diagnosis and management. Dysphagia intervention may concentrate on swallowing exercises, compensatory swallowing strategies (including posture considerations), bolus consistency modification, and caregiver/patient education.
Incidence refers to the number of new cases of dysphagia identified in a specified time period. Prevalence refers to the number of people who are living with dysphagia in a given time period.
Each year, approximately one in 25 adults will experience a swallowing problem in the United States (Bhattacharyya, 2014). Dysphagia cuts across so many diseases and age groups that its true prevalence in adult populations is not fully known and is often underestimated.
A number of epidemiologic reports indicate that the prevalence of dysphagia is more common among older individuals and that sarcopenia is positively associated with dysphagia (Barczi et al., 2000; Bhattacharyya, 2014; Bloem et al., 1990; Cabré et al., 2014; Roden & Altman, 2013; Sura et al., 2012; Zhao et al., 2018). Conservative estimates suggest that dysphagia rates may be
Advanced age is a risk factor for aspiration pneumonia (Loeb et al., 1999). A report by the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) estimates that approximately one third of patients with dysphagia develop pneumonia and that 60,000 individuals die each year from such complications (Agency for Health Care Policy and Research, 1999). The prevalence of dysphagia in community-dwelling adults over the age of 50 years is estimated to be somewhere between 15% and 22% (Aslam & Vaezi, 2013; Barczi et al., 2000), and in skilled nursing facilities, the prevalence rises to over 60% (Steele et al., 1997; Suiter & Gosa, 2019).
Various neurological diseases are known to be associated with dysphagia. The exact epidemiological numbers by condition or disease also remain poorly defined. This, in part, is due to the concomitant medical conditions being reported and the timing and type of diagnostic procedures being used to identify swallowing disorders across neurological populations. Other studies have such findings as follows:
Not all signs and symptoms are seen in all types of dysphagia, and the evidence supporting the predictive value of these signs and symptoms is mixed. For example, coughing and throat clearing may not be correlated with penetration or aspiration of a bolus but may be the result of gastroesophageal reflux, esophageal dysmotility, and common medications (Elvevi et al., 2014; Madanick, 2013; Tafreshi & Weinacker, 1999). Signs and symptoms of dysphagia include
Silent aspiration may be present, meaning the patient presents without overt signs or symptoms of dysphagia.
It is important to consider signs and symptoms of dysphagia in the context of other clinical indicators such as the etiology of the dysphagia and the overall health of the patient, rather than relying on a single sign or symptom.
Dysphagia may develop secondary to damage to the central nervous system (CNS) and/or cranial nerves, and to unilateral or bilateral cortical and subcortical lesions, such as
Dysphagia may also occur from problems affecting the head and neck, including
Dysphagia may be associated with other factors, such as
Knowledge, skills, and clinical experience related to the evaluation and management of individuals with swallowing and swallowing problems may be acquired on the graduate or postgraduate level, in formal coursework, and/or via continuing education. The standards for ASHA certification effective in 2020 require competence in dysphagia. The American Board of Swallowing and Swallowing Disorders, under the auspices of ASHA’s specialty certification program, offers clinical specialty certification in swallowing and swallowing disorders. Specialty certification is a voluntary program and is not required by ASHA to practice in any disorder area. Board Certified Specialists in Swallowing and Swallowing Disorders are individuals who hold ASHA certification and have demonstrated advanced knowledge and clinical expertise in diagnosing and treating individuals with swallowing disorders.
SLPs have knowledge of the anatomy, physiology, and functional aspects of the upper aerodigestive tract as they relate to swallowing and speech. SLPs also have expertise in communication disorders that may affect the diagnosis and management of swallowing disorders. SLPs work collaboratively with other professionals, individuals, families, and caregivers. Interprofessional practice (IPP) is critical to successfully achieving the desired improvements and outcomes due to complexities of assessment and treatment of swallowing disorders.
SLPs play a central role in the assessment and management of individuals with swallowing disorders. An SLP’s roles include
As indicated in the ASHA Code of Ethics (American Speech-Language-Hearing Association [ASHA], 2016), SLPs who serve this population should be specifically educated and appropriately trained to do so. SLPs should maintain competency of skills through reading current research and engaging in continuing education.
The causes and consequences of dysphagia cross traditional boundaries between professional disciplines. Therefore, management of dysphagia may require input of multiple specialists serving on an interprofessional team. Members of the dysphagia team may vary across settings.
The SLP frequently serves as a coordinator for the team management of dysphagia. SLPs lead the team in
See the Assessment section of the Dysphagia Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Screening identifies the need for further assessment and may be completed prior to a comprehensive evaluation. Swallowing screening is a procedure to identify individuals who require a comprehensive assessment of swallowing function or a referral for other professional and/or medical services (ASHA, 2004). Screening for dysphagia may be conducted by an SLP or any other member of the patient’s care team. Individuals of all ages are screened as needed, requested, or mandated or when presenting medical conditions (e.g., neurological or structural deficits) suggest that they are at risk for dysphagia. The purpose of the screening is to determine the likelihood that dysphagia exists and the need for further swallowing assessment (see ASHA’s resource on Swallowing Screening). It is important to note that, currently, no bedside screening protocol has been shown to provide adequate predictive value for the presence of aspiration. Several tools have demonstrated reasonable sensitivity, but reproducibility and consistency of these protocols have not been established (O’Horo et al., 2015). During any screening process, the members of the patient care team may note proper posture and positioning for eating, as well as any potential sensory deficits that may affect swallowing.
Screening may include the following:
All screening procedures include communication of results and recommendations to the team responsible for the individual’s care and to the patient and caregivers.
Screening may result in
The medical team may make temporary recommendations (e.g., no oral intake, stipulation of specific dietary precautions) while the patient is awaiting further assessment.
Assessment and treatment of swallowing and swallowing disorders includes consideration of infection control and personal protective equipment (PPE) as necessary. Special considerations may need to be made regarding PPE for COVID-19. For further information see ASHA’s resource on Aerosol Generating Procedures. Consistent with the World Health Organization’s (2001) International Classification of Functioning, Disability and Health framework, the purpose of assessment is to identify and describe
Comprehensive assessment includes non-instrumental and instrumental procedures. Instrumental procedures may not be indicated in select patients (e.g., a patient with ill-fitting dentures resulting in oral dysphagia or some patients with low levels of alertness who are unable to participate in the study). Instrumental procedures are the only method that provides visualization of swallowing physiology and laryngeal, pharyngeal, and upper esophageal anatomy, which help diagnose dysphagia.
Swallowing assessment allows the SLP to integrate information from the following:
Assessment may result in one or more of the following outcomes:
Patients with suspected dysphagia may warrant further instrumental assessment to examine the impact of swallowing anatomy and physiology on clinical presentation (McCullough et al., 2005; O’Horo et al., 2015). Patients may also require further assessment or reassessment depending on changes in functional or medical status. SLPs may make recommendations for modifications of texture and viscosity and discuss their implications with other team members (e.g., dietary team, the patient). Ongoing assessment can also include evaluation of changes in patients’ swallow function as a result of intervention, including diet modification, while implementing a plan of care.
SLPs conduct assessments in a manner that is sensitive to the individual’s cultural background, religious beliefs, and preferences for medical treatment (see ASHA’s Practice Portal page on Cultural Responsiveness for additional information). SLPs should consider how culture influences activities of daily living (Riquelme, 2004). For example, spiritual practices that involve food and drink might be impacted by diet modifications. Using ethnographic interviewing strategies during the assessment process is an excellent way to gather information about an individual’s specific needs (Westby et al., 2003). SLPs should discuss any dietary texture/consistency-related changes with the patient and caregivers who prepare food. In some cases, caregivers may be encouraged to bring familiar food and drink.
The purpose of a non-instrumental swallowing assessment is to determine the presence (or absence) of signs and symptoms of dysphagia, with consideration for factors such as fatigue during a meal, posture, positioning, and environmental conditions. Verification of aspiration and thorough assessment of impairments in swallowing physiology or laryngeal/pharyngeal/upper esophageal anatomy require instrumental assessment.
A non-instrumental swallowing assessment may include a medical chart review as well as an assessment or consideration of
During or following bolus delivery during per os (P.O.) trials including consistencies typically consumed by the patient in their natural environment, the SLP may assess
The clinical examination may inform recommendations for the management of dysphagia (Garand et al., 2020), including
The non-instrumental assessment of swallowing is insufficient to infer specific information about laryngeal, pharyngeal, or upper esophageal anatomy and physiology required to develop effective treatment options and prevent consequences of dysphagia, such as dehydration, malnutrition, pneumonia, and death (Garand et al., 2020).
SLPs use instrumental techniques to evaluate oral, pharyngeal, laryngeal, upper esophageal, and respiratory function as they apply to normal and abnormal swallowing. Instrumental procedures are also used to determine appropriateness and effectiveness of treatment strategies.
In clinical settings, SLPs typically use one of two types of instrumental evaluation: the videofluoroscopic swallowing study (VFSS) or the flexible endoscopic evaluation of swallowing (FEES), sometimes also called fiber-optic endoscopic evaluation of swallowing. The VFSS is also known as the modified barium swallow study (MBSS) and is a radiographic procedure used to gain further information regarding dysphagia. Please see ASHA’s resource on the Videofluroscopic Swallowing Study for further information on the VFSS. The FEES is a portable procedure that may be completed in outpatient clinic space or at bedside by passing an endoscope transnasally (Langmore et al., 1988). Please see ASHA’s resource on Flexible Endoscopic Evaluation of Swallowing for further information on the FEES.
Instrumental techniques are usually conducted either independently by the SLP or by the SLP in conjunction with other members of the interprofessional team (e.g., radiologist, radiologic technologist, physiatrist, otolaryngologist). SLPs help guide medical decision making regarding the appropriateness of these procedures given the severity and nature of the patient’s swallowing deficits. SLPs interpret and apply the results of imaging to dysphagia treatment plans and make recommendations and referrals as appropriate. SLPs do not require special certification from any entity to perform instrumental assessments. However, per the ASHA Code of Ethics, SLPs should have appropriate training and demonstrate competency before completing instrumental techniques. Instrumental assessments may be recommended and completed regardless of setting (e.g., hospital, skilled nursing facility) in which the services are delivered.
Indications for an instrumental exam include the following:
General contraindications for an instrumental exam include, but are not limited to, the following:
Instrumental assessment may include components of non-instrumental swallowing assessment (see above for further details). The purpose of the instrumental examination is to enable the SLP to perform the following tasks:
Implementation of any instrumental procedure requires the SLP to have advanced knowledge and specific skills in order to
Qualified SLPs may also screen for esophageal motility and gastroesophageal reflux disease (GERD) to identify the need for appropriate referral. Oropharyngeal function may be potentially affected in some patients with esophageal motility issues.
ASHA recognizes the autonomy of SLPs in completing the VFSS. However, other parties (e.g., state regulatory agencies) may require a radiologist to be present during the VFSS. For further information please see ASHA’s resource on the Videofluroscopic Swallowing Study.
Other instrumental procedures are used primarily in research at this time but may develop into clinical diagnostic tools. Ultrasonography involves the use of a transducer to observe movement of structures used for swallowing, such as the tongue and hyoid (Hsiao et al., 2013; Sonies et al., 2003). High-resolution manometry is a technique used to measure pressures generated in the pharynx and esophagus. A thin catheter with pressure sensors < 1 cm apart is placed through the nose, pharynx, and esophagus. Various pressure measures can be calculated and compared to normative data (Omari & Schar, 2018).
SLPs should also be familiar with other diagnostic procedures performed by different medical specialists that yield information about swallowing function. These include procedures such as the esophagram/barium swallow, manofluorography, scintigraphy, 24-hr pH monitoring, and esophagoscopy.
See the Treatment section of the Dysphagia Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
The primary goals of dysphagia intervention are to
Management of individuals with dysphagia should be based on results of comprehensive assessment, including both instrumental and non-instrumental assessments as applicable. Decision making must take into account many factors about each individual’s overall status and prognosis. This might include information concerning the individual’s health and diagnosis, prognosis, cognition, social situation, cultural values, economic status, motivation, and personal choice. Maintenance and/or maximization of an individual’s health status is a primary concern. The SLP should consider and integrate the patient’s wishes and advocate on behalf of the patient to the health care team, the family, and other relevant individuals.
Consideration of the underlying neurophysiological impairment is necessary for understanding swallow function and deficits. Different management approaches may be necessary for individuals with dysphagia that has resulted from an acute event, a chronic/stable condition, or a progressive neurological disorder. Treatment targeting a specific function or structure may also affect function in other structures.
Treatment of dysphagia may include restoration of normal swallow function (rehabilitative) and/or modifications to diet consistency and patient behavior (compensatory).
Rehabilitative techniques, such as exercises, are designed to create lasting change in an individual’s swallowing over time by improving underlying physiological function. The intent of many exercises is to provide lasting functional improvement.
Compensatory techniques alter the swallow when used but do not create lasting functional change. An example of a compensatory technique includes a head rotation, which is used during the swallow to direct the bolus toward one of the lateral channels of the pharyngeal cavity. Although this technique may increase swallow safety and/or efficiency during the swallow, there is no lasting benefit or improvement in physiology. The purpose of the technique is to compensate for deficits that cannot be or are not yet rehabilitated sufficiently.
Some techniques may be used for both compensatory and rehabilitative purposes. For example, the super-supraglottic swallow is a rehabilitative technique that increases closure at the entrance to the airway and may also serve as a compensation to protect the airway (McCabe et al., 2009).
Upon completion of the comprehensive assessment, the clinician uses the acquired data to identify which treatment options would be most beneficial. Treatment options for patients with dysphagia are selected on the basis of evidence-based practice, which includes a combination of the best available internal and external evidence. This includes external scientific research as well as data gathered on a specific person. Internal and external evidence may come from
Treatment options should be selected on a case-by-case basis as there are many etiologies of dysphagia. Clinicians should be aware that research into the overall efficacy of dysphagia treatment is ongoing; therefore, treatment options may evolve. Please see ASHA’s Dysphagia Evidence Map.
Biofeedback incorporates the patient’s ability to sense changes and aids in the treatment of feeding or swallowing disorders. For example, patients with sufficient cognitive skills can be taught to interpret the visual information provided by these assessments (e.g., surface electromyography, ultrasound, flexible endoscopic evaluation of swallowing [FEES], manometry, Iowa Oral Performance Instrument [IOPI], or mirror) and to make physiological changes during the swallowing process.
Modifications to the texture of the food may be implemented to facilitate safe oral intake. This may include changing the viscosity of liquids and/or softening, chopping, or pureeing solid foods (International Dysphagia Diet Standardisation Initiative [IDDSI]). Modifications of the taste or temperature may also be employed to change the sensory input of the bolus. Clinicians consult with the patients and caregivers to identify patient preference and values for food when discussing modifications to oral intake. Consulting with the team, including a dietician, when altering a diet can help ensure that the patient’s nutritional needs continue to be met.
Although the body of literature concerning the value of electrical stimulation for swallowing is large, the benefits remain unclear (Carnaby-Mann & Crary, 2007; Clark et al., 2009; Humbert et al., 2012; Sun et al., 2020). Electrical stimulation uses an electrical current in order to stimulate the peripheral nerve. SLPs with appropriate training and competence in performing electrical stimulation may provide the intervention. ASHA does not require any additional certifications.
Patients may benefit from the use of adaptive equipment or environmental modifications to more effectively manage the bolus (Granell et al., 2012). SLPs collaborate with other team members in identifying and implementing use of adaptive equipment.
Maneuvers are specific strategies that clinicians use to change the timing or strength of particular movements of swallowing. Some maneuvers require following multistep directions and may not be appropriate for patients with cognitive impairments. Examples of maneuvers include the following:
Swallowing exercises include exercises of the lips, jaw, tongue, soft palate, pharynx, larynx, and/or respiratory muscles to improve function. Some of these interventions can also incorporate sensory stimulation. Oral-motor treatments range from passive to active (e.g., range-of-motion activities, resistance exercises, or chewing and swallowing exercises). Examples of exercises include the following:
Specific bolus volumes per swallow may result in faster pharyngeal swallow responses (Barikroo et al., 2015). Clinicians modify bolus size particularly for patients that require a greater volume to adequately stimulate a swallow response (increase bolus size) or for patients that require multiple swallows per bolus (decrease bolus size). Patients may also require cuing and assistance to maintain an appropriate rate during meals. Cognitive deficits (e.g., impulsivity, decreased initiation) may affect a patient’s pace during meals.
Postural techniques redirect the movement of the bolus in the oral cavity and pharynx and modify pharyngeal dimensions. Postural techniques may be appropriate to use with patients with neurological impairments, head and neck cancer resections, and other structure damage. Examples of postural techniques include the following:
Postures and maneuvers may be combined, taking care to minimize patient effort/burden when possible.
Prosthetics (e.g., palatal obturator, palatal lift prosthesis) can be used to normalize pressure and movement in the intraoral cavity by providing compensation or physical support for patients with structural deficits/damage to the oropharyngeal mechanism. With this support, swallowing efficiency and function may be improved. Intraoral appliances (e.g., palatal plates) are removable devices with small knobs that provide tactile stimulation inside the mouth to encourage lip closure and appropriate lip and tongue position for improved swallow function. This treatment option is most often used with patients following treatment for head and neck cancer; however, it may be implemented with other patients suffering from similar challenges.
Patients who are tactically defensive may need approaches that reduce the level of sensory input initially, with incremental increases as tolerance improves. Sensory stimulation may be useful for those with reduced response, overactive response, or limited opportunity for sensory experience.
Due to the interprofessional nature of dysphagia management, clinicians should be aware of multiple options for dysphagia intervention, including medical, surgical, and behavioral treatment. Such knowledge increases pertinent communication with other health care providers and facilitates selection of the best treatment options for individual patients (Groher & Crary, 2010).
Improved Glottal Closure
Improved Pharyngoesophageal Segment Opening
If the individual’s swallowing does not support nutrition and hydration via oral intake, the swallowing and feeding team may recommend alternative avenues of intake (e.g., nasogastric [NG] tube, gastrostomy). In these instances, team members consider whether the individual will need the alternative source for a short or an extended period of time. Education and counseling may be provided concerning issues related to tube feeding, such as appropriate positioning and duration of feeding times.
Alternative feeding does not preclude the need for rehabilitative techniques to facilitate sensory and motor capabilities necessary for oral feeding. Percutaneous endoscopic gastrostomy (PEG) tubes may not be appropriate in all populations and may not necessarily improve outcomes or quality of life (Ayman et al., 2016; Plonk, 2005). Please see ASHA’s resource on Alternative Nutrition and Hydration in Dysphagia Care for further information.
The decision to recommend use of a feeding tube is made in collaboration with the medical team. The physician is ultimately responsible for selecting which type of tube is used, but a brief description of several options is provided below.
The patient, with their proxy, then chooses to accept or reject use of alternative nutrition and hydration following a shared decision making, informed consent discussion.
The role of the SLP in treating individuals with progressive neurological disorders is designed to maximize current function, compensate for irreversible loss of function, assess and reassess changes in status, and educate and counsel patients regarding the progression of the disorder and potential options, including non-oral means of nutrition.
SLPs may encounter patients approaching the end of life. These patients may have complex medical conditions related to feeding and swallowing. SLPs may work with these patients and caregivers to develop compensatory strategies that will allow the patients to eat an oral diet for as long as they desire. As a member of the interprofessional team, the SLP may contribute to decision making regarding the use of alternative nutrition and hydration. SLPs may also make recommendations regarding continuing per os (P.O.) intake as pleasure feeds given extensive education to the patient, the patient’s family/caregiver(s), and the clinical/medical team.
Understanding emotional and psychological issues related to death is essential to treating patients with swallowing problems at the end of life. When considering end-of-life issues, it is important for clinicians to respect the patient’s wishes, including social and cultural considerations. Patients and caregivers may not agree with clinical recommendations and may feel that these recommendations do not provide the best quality of life for their loved one.
One model for ethical decision making includes consideration of the following (Jonsen et al., 1992):
Clinicians provide information regarding these considerations without factoring in their own personal beliefs. Conflict may occur when medical recommendations do not match patient preferences. A patient with decision-making capacity, the patient’s family, or other established decision-maker has the right to accept or refuse such recommendations (Krekeler et al., 2018). After being educated about the risks and benefits of a particular recommendation (e.g., oral vs. non-oral means of nutrition, diet level, rehabilitative technique), if a patient (or their decision-maker) chooses an alternate course of action, the SLP makes recommendations and offers treatment as appropriate. The SLP educates involved parties on possible health consequences and documents all communication with the patient and caretakers (Horner et al., 2016). If no treatment is warranted, then the SLP may make recommendations about the safest course of intake (and still document the risks of such action) and may provide training to caregivers and family, as appropriate. The SLP may then decide to discontinue speech-language pathology services to the patient but should avail themselves to additional consultation or communication with the parties involved, as appropriate. Palliative care teams can assist a patient and/or family in establishing goals of care, which can then guide some of these complex decisions. Many facilities have an ethics consultation service that can help clinicians, patients, and families address challenges when an ethical issue arises.
See the Service Delivery section of the Dysphagia Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
In addition to determining the type of assessment and treatment that is optimal for adults with dysphagia, SLPs consider other service delivery variables that may affect swallowing outcomes—variables such as format, provider, dosage, and timing.
Format refers to the structure of the assessment or treatment session, such as whether a person is seen for treatment one on one (i.e., individual), as part of a group during mealtime, or via telepractice. Please see ASHA’s Practice Portal page on Telepractice for further detail.
Provider refers to the person providing the assessment or treatment (e.g., SLP, trained volunteer, caregiver).
Dosage primarily refers to the amount of treatment provided (e.g., the frequency, intensity, and duration of service).
Timing refers to the timing of rehabilitation relative to the onset of dysphagia.
Setting refers to the location of treatment (e.g., home-based, community-based).
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