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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 maintain nutritional needs, a speech therapist may teach your loved one ways to improve swallowing.

Senior man drinking tea. His wife is drinking orange juice and smiling at him.
For your loved one’s safety, prepare all food and drink exactly as directed.

Learning new ways to eat

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.

Increasing muscle control

Many people are helped by exercises. Some 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.

Food and drink guide

The speech therapist will teach you which food textures and liquids your loved one can swallow safely. Discuss examples using foods he or she likes. 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. The levels are:

Liquid levels

  • Level 0 (thin). These are watery liquids such as juice, tea, milk, soda, beer, and broth. You can drink them through a nipple, cup, or straw.

  • Level 1 (slightly thick). These are thicker than water. They require more effort to drink than thinner liquids but still flow through a straw or nipple.

  • Level 2 (mildly thick). These liquids flow off a spoon but more slowly than thinner drinks. They can be sipped or sucked from a straw with some effort.

  • Level 3 (liquidized, moderately thick). You can drink these from a cup or sucked from 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.

Food levels

  • 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. For example, not stiff like molded gelatin.

  • Level 4 (pureed, extremely thick). These foods:

    • Can often be eaten with a spoon, but sometimes a fork

    • Can't be drunk from a cup

    • Don't need to be chewed

    • Can be molded, such as gelatin

    • Are not sticky or lumpy

    • Fall off a spoon all together when tilted and still hold shape on a plate. For example, 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 a chopstick if you have good hand control

    • Can be scooped and shaped on a plate. For example, 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, and hard and crunchy

    • Foods that can be eaten by any method. For example, 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

Online Medical Reviewer: Anne Fetterman RN BSN
Online Medical Reviewer: Mary Mancini MD
Online Medical Reviewer: Raymond Kent Turley BSN MSN RN
Date Last Reviewed: 12/1/2019
© 2000-2020 The StayWell Company, LLC. 800 Township Line Road, Yardley, PA 19067. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions.
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