Assessment of Swallowing in Patients

Initial Clinical Evaluation

• The American Geriatrics Society recommends that swallowing assessment should begin with a clinical evaluation by a speech-language pathologist (SLP), followed by instrumental assessment when indicated, as bedside evaluations alone are insufficient to determine treatment interventions for dysphagia 1, 2, 3
• Signs and symptoms that warrant swallowing assessment include coughing while swallowing, nasal regurgitation of food, wet vocal quality after swallowing, poor secretion management, weak cough, or feeling of food getting stuck 2, 3
• The clinical evaluation should include a thorough review of medical history 1, interview with patient and/or caregiver 1, cranial nerve examination 1, 2, and assessment of lip closure and evidence of saliva pooling 4
• The American Geriatrics Society suggests using structured screening tools with validated diagnostic performance, such as the EAT-10 questionnaire (sensitivity 86%, specificity 76% for identifying aspiration) 5, 6

Instrumental Assessment

• The American Geriatrics Society recommends instrumental assessment when signs of dysphagia are present at clinical evaluation 1, 2, silent aspiration is suspected (particularly in older adults) 1, 2, 3, or the clinical scenario is unclear 1, 2
• Videofluoroscopic Swallowing Study (VFSS) is the most common instrumental assessment 1, 2, 6, which allows determination of specific swallowing impairments 1 and evaluates safety and efficiency of swallow 1, 2
• Fiberoptic Endoscopic Evaluation of Swallowing (FEES) is another type of instrumental assessment, which allows visualization of pharyngeal and laryngeal anatomy 1, 6 and can be performed at bedside 6

Special Considerations

• The American Geriatrics Society recommends that patient must be able to participate in the assessment; performing swallowing assessments on delirious patients may be futile 1, 2, 3
• Older adults have higher rates of silent aspiration, making clinical bedside evaluations less reliable 1, 2, 3
• For patients with suspected esophageal dysphagia, endoscopy or barium swallow (esophagram) is typically used 2, 3
• Regular assessment of swallowing function is recommended every 3 months in patients with ALS 4

Common Pitfalls and Caveats

• Aspiration on VFSS predicts rehospitalization but not necessarily pneumonia or pneumonia death in nursing home patients 1
• A person may have asymptomatic swallowing disorder; in one study, 55% of patients who aspirated had silent aspiration with absence of protective cough reflex 6

Difficulty Swallowing Tablets and Indications for SALT Assessment

Indications for SALT Assessment

• The American Thoracic Society recommends SALT referral when tablet-swallowing difficulty occurs alongside clinical signs of oropharyngeal dysphagia, such as coughing or choking while eating or drinking, wet or gurgly vocal quality after swallowing, poor secretion management, weak voluntary cough, dysarthria or dysphonia, malnutrition, unintentional weight loss, or dehydration, or history of aspiration pneumonia or abnormal chest radiograph in patients with neurological conditions, structural abnormalities, or reduced level of consciousness 7, 8
• Patients with neurological conditions, such as stroke, Parkinson's disease, dementia, ALS, or multiple sclerosis, should be referred for SALT assessment even with isolated tablet difficulty 7
• The American College of Chest Physicians suggests that patients with structural abnormalities, such as head/neck cancer or prior radiation therapy, should be referred for SALT assessment 7
• Patients with reduced level of consciousness or lethargy should be referred for SALT assessment 7, 8

High-Risk Populations

• The American Geriatrics Society recommends that patients over 65 with multiple comorbidities should be referred for SALT assessment due to higher silent aspiration risk 7, 8

Swallow Test Ordering Guidelines

Patient Identification and Referral

• The American College of Chest Physicians recommends that healthcare providers refer patients with suspected dysphagia directly to a Speech-Language Pathologist (SLP) for an oropharyngeal swallow evaluation, which includes both clinical bedside assessment and instrumental testing (videofluoroscopic swallow evaluation [VSE] or fiberoptic endoscopic evaluation of swallowing [FEES]) to guide treatment decisions 9, 10
• Patients with neurological conditions, such as stroke, Parkinson disease, dementia, ALS, multiple sclerosis, or brain injury, should be referred to an SLP for evaluation 9, 10
• Patients with cough associated with eating or drinking, or a history of aspiration pneumonia, should be referred to an SLP for evaluation 9, 10
• Patients with unintentional weight loss, malnutrition, or dehydration should be referred to an SLP for evaluation 9, 10
• Patients with abnormal chest radiograph showing patchy opacity, lower lobe infiltrate, or air space disease should be referred to an SLP for evaluation 9, 10

Clinical Evaluation and Instrumental Testing

• The SLP performs a bedside clinical swallow evaluation that includes observation of swallowing with various consistencies, and assessment of lip closure and saliva pooling 10
• Instrumental assessment, such as VSE or FEES, is essential to directly visualize aspiration and penetration, identify which therapeutic techniques eliminate aspiration, and detect silent aspiration (aspiration without cough reflex) 9, 11
• VSE is the gold standard and provides motion picture radiography of swallowing structures with barium-mixed food/liquid in lateral and anterior-posterior positions 11
• FEES can be performed at bedside and provides direct visualization of pharyngeal and laryngeal anatomy before and after swallowing 11

Treatment and Management

• The American College of Chest Physicians emphasizes that instrumental assessment is not just diagnostic but therapeutic—it determines which specific interventions will prevent aspiration during oral feeding 11
• Implementation of SLP screening and evaluation programs has resulted in dramatic reductions in aspiration pneumonia rates 11
• The referral/order should be written as "Consult Speech-Language Pathology for dysphagia evaluation including clinical swallow assessment and instrumental testing (VSE or FEES) to determine aspiration risk and guide treatment recommendations" 9, 10

ACCP Guidelines for Prompt Home‑Health SLP Referral in High‑Risk Dysphagia Patients

Patient Demographics & Diagnosis

• A 78‑year‑old individual who suffered a left middle cerebral artery ischemic stroke and has mild Alzheimer disease should be considered for dysphagia evaluation. [12][13]

High‑Risk Clinical Indicators

• Recent aspiration pneumonia alone mandates a speech‑language pathology (SLP) referral according to the American College of Chest Physicians (ACCP) guidelines. [12][13]
• Witnessed coughing during meals demonstrates 74 % sensitivity and 74 % specificity for detecting aspiration. [12][13]
• Unintentional weight loss of approximately 4 kg signals malnutrition and raises suspicion for aspiration. [12][13]
• The combination of stroke, witnessed coughing, recent aspiration pneumonia, and weight loss yields a 91 % sensitivity for identifying oropharyngeal dysphagia and aspiration. [12][13]
• The patient is currently consuming thin liquids and pureed foods, indicating ongoing oral intake despite risk factors. [12][13]
• The patient is alert and able to cooperate with assessment, satisfying a key criterion for safe bedside evaluation. [12][13]

Assessment Recommendations

• Evaluation of voluntary cough strength should be included in the bedside SLP assessment to help gauge aspiration risk. [12][13]

Referral Timing & Urgency

• ACCP guidelines issue a Grade B recommendation (substantial benefit) that individuals with the above high‑risk conditions must receive an oral‑pharyngeal swallowing evaluation without delay. [12][13]
• Referral should not be postponed unless the patient is lethargic, has absent swallow response on command, a respiratory rate > 35 breaths/min, or is delirious; otherwise, immediate evaluation is required. [12][13]