Aspiration pneumonia: swallowing problems and chest infections in older people

The NHS describes pneumonia as inflammation of the lungs usually caused by infection, and says it can be caused by something getting into the lungs such as water or food (aspiration pneumonia). The Stroke Association explains why: the mouth holds high numbers of bacteria, and if these enter the airway they can lead to pneumonia. Even saliva can reach the airway if someone cannot swallow properly, or is drowsy and cannot cough normally.

Normally, a flap in the throat (the epiglottis) closes over the airway at the moment of swallowing, and the body coughs if something goes the wrong way. Parkinson's UK points out that when the cough reflex is weaker, the risk of aspiration pneumonia is higher.

Swallowing problems (dysphagia) develop gradually and may not be noticed at first, so family and carers should know what to look for. Drawing on the NHS, Parkinson's UK and the Stroke Association, the signs include:

• Coughing or choking when eating or drinking.

• A gurgly, wet or croaky voice, particularly after a drink.

• Food or drink going down the wrong way, or food stuck in the throat or chest.

• Bringing food back up, sometimes through the nose.

• Drooling, or saliva escaping from the mouth.

• Taking a very long time to finish a meal, or having to swallow repeatedly.

• Shortness of breath when swallowing, or after eating or drinking.

• Weight loss, dehydration, fear of eating, or repeated chest infections.

The NHS says dysphagia is usually caused by another health condition: a stroke, dementia, multiple sclerosis, cerebral palsy, acid reflux, cancer of the mouth or oesophagus, breathing problems from conditions such as COPD, or certain medicines such as antipsychotics. Parkinson's UK adds that stiffness and slowness of the jaw, tongue and throat muscles, and weakened throat muscles, reflexes and sensation, can make swallowing less efficient in Parkinson's disease. The NHS also notes advanced Alzheimer's disease can cause swallowing problems and aspiration. Asthma + Lung UK says over-65s and people with a lung condition, malnutrition or a learning disability are more at risk of pneumonia generally.

After a stroke, the Stroke Association says swallowing is affected when the damage involves the parts of the brain that coordinate the muscles, and also when an affected arm, weak face or lip muscles, poor sitting balance, drowsiness or poor concentration interfere. Most people are able to swallow safely again within the first few weeks, while a small number have longer-lasting problems.

Parkinson's UK lists chest pain, finding it difficult or painful to breathe, a cough with phlegm or blood and fever as symptoms of aspiration pneumonia, normally treated with antibiotics; it advises contacting the healthcare team straight away or calling NHS 111 if they are not available. The Stroke Association lists high temperature, aches, feeling generally unwell, difficulty breathing, chest pain and feeling confused. The NHS lists confusion as common in older people and says to call 999 for struggling to breathe, blue or blotchy skin or lips, coughing up blood or sudden confusion. Parkinson's UK says severe choking where the person cannot breathe, cough or speak is a medical emergency needing a 999 call.

The NHS says a GP will examine you and may refer you to a specialist or to a speech and language therapist or dietitian. Treatment depends on cause and severity, and may include swallowing therapy, softer foods and thickener in drinks, special spoons, plates and cups, and feeding tubes through the nose or into the stomach. The Stroke Association describes the speech and language therapist assessing what is going on, with the first priority to make swallowing safe, using changes to how someone eats and drinks, swallowing techniques, aids and exercises to strengthen muscles.

The Stroke Association also explains that thin liquids are the hardest to control, so a therapist may assess whether thickened drinks help; some people need soft or pureed food, cooler food rather than hot, and small amounts through the day. Texture and thickener advice is specific to the person, so do not adjust diet without the therapist's recommendations. Parkinson's UK says a dietitian can help if weight loss is unintentional, and a specialist or Parkinson's nurse may suggest a patch or liquid if tablets are hard to swallow.

Report new coughing at mealtimes, a wet voice or weight loss to the GP or care team early rather than waiting for a chest infection. Ask that the swallowing advice from the therapist is written down and shared with every carer, care home and hospital ward, as the Stroke Association says the therapist makes sure the rest of the team are clear about what can and cannot be eaten and how. Parkinson's UK suggests asking a healthcare professional to show a friend or carer what they could do if someone is choking. Good mouth care is relevant because of the bacteria involved, though the sources read here do not give a specific regime.