These speech therapists are teaching patients to swallow again.

Most of us never think about swallowing, which we do at least once every minute. But for about 1 in 20 people in the U.S., swallowing is not automatic, and that can be frightening.

When the reflex that allows us to eat, drink and clear our throats no longer works, it’s often a sign of a deeper medical problem. Difficulty swallowing, known as dysphagia, can be caused by medical conditions including stroke, dementia, Parkinson’s disease, neck or throat cancer and traumatic brain injury.

Regaining control of those muscles is a critical part of speech therapy.

“Most of our day is focused on helping people who are having trouble swallowing to safely eat and drink again,” said Sarah Hyde Foster, a speech-language pathologist at Novant Health New Hanover Regional Medical Center in Wilmington.

These specialists, also known as speech therapists, hold master’s degrees in speech-language pathology. They work 365 days a year to assess patient risk, guide treatment and help prevent atrophy before swallowing problems become life threatening.

A growing team to meet a growing need

The rising elderly population is fueling demand for speech therapy treatment nationwide. That’s because people older than 65 are most likely to develop neurological disorders like stroke and dementia, which can weaken the muscles and nerves needed for swallowing and speaking.

Over the last two decades, the speech-language pathology staff at New Hanover Regional Medical Center has expanded to 11 therapists. They exclusively see patients in the hospital by provider referral. The busiest time of year is winter, when respiratory illnesses surge, Hyde Foster said.

When swallowing becomes dangerous

More than 7 million people in the U.S. have dementia, with cases expected to double by 2060. Dementia affects the brain’s ability to control swallowing and can lead to pneumonia when food or drink goes down the windpipe.

“People with advanced dementia often develop pneumonia due to no longer swallowing the way they should,” Hyde Foster said. “This can cause further complications, including death.”

Even more concerning, some patients don’t realize they’re struggling to swallow. Normally, when food or drink goes down the wrong pipe, the body naturally reacts by coughing or clearing the throat. But a past stroke or radiation treatment can dull that reflex and allow food or liquid to enter the lungs without warning.

How swallowing is evaluated

Trouble swallowing can follow a stroke or other neurological injury. A speech therapist evaluates the patient to determine what's safe to eat or drink.

• What caused the problem? Any number of medical conditions, including a brain injury or even gastroesophageal reflux disease, could be responsible. The team considers the patient’s diagnosis and medical history to determine treatment steps.
• How severe is it? The team assesses how patients swallow foods of different textures.
• Is the patient at risk? Hyde Foster recalls treating a throat cancer survivor whose swallowing muscles were damaged by radiation decades before. The issue became clear only after the patient developed pneumonia.

Depending on the patient, speech therapists may use one of the following tests to guide treatment:

• A modified barium swallow is a diagnostic X-ray that shows how food and liquid move through the throat. Patients swallow barium, a chalky liquid that coats the digestive tract, mixed with food so that a radiologist can capture images of how the foods move through the mouth and throat as they chew and swallow.
• A fiberoptic endoscopic evaluation of swallowing during which a clinician inserts a thin scope through the nose to assess how well different consistencies pass through the throat. This generally takes less than an hour.

From there, speech therapists consider nutrition versus safety.

So, what can people with swallowing problems eat?

That’s the question families ask most often.

“We have hard conversations,” said Alicia East, who supervises acute care rehabilitation services at Novant Health New Hanover Regional Medical Center — a team that includes speech, occupational and physical therapy. “Telling somebody their loved one is not safe to have food or drink right now is difficult.”

The team weighs risk versus reward. Initially, most patients can have ice chips, which melt quickly and encourage swallowing. When food is allowed, soft options like applesauce and pudding are common. They’re easy to swallow, gentle on the throat and help with exercising the muscles to improve swallowing function.

“We want our patients to be safe and to be on the least restrictive diet possible,” East said. “A huge part of what we’re doing is providing that comfort piece and restoring a sense of normalcy.”

That comfort extends to holidays, like Thanksgiving. While many families outside the hospital gather for a feast, this team whips up some festive bedside spirit.

“Around the holidays our job is especially rewarding on a day that’s all about eating,” Hyde Foster said. “We get to be the ones to show up and say, ‘Hey, you get to eat!’”

More than swallowing

Speech therapists also assist patients with memory, attention, impulse control and problem-solving. They assess both expressive language (how well the patient can communicate) and receptive language (how well they understand others).

East, who has been with New Hanover Regional Medical Center since 2007, found speech-language pathology through her love of language. She started as a pre-med student at the University of North Carolina at Chapel Hill, but decided to major in linguistics instead. Between learning Hindi, Spanish and Latin, she couldn’t get enough.

Hyde Foster also didn’t originally plan on pursuing speech therapy. While studying pre-nursing at the University of North Carolina at Greensboro, she realized it wasn’t the right fit. Hearing family stories about her grandfather, who died from lymphoma and related swallowing problems, led her to speech-language pathology.

Today, she and the other therapists work to meet their patients’ needs throughout treatment. This helps them build trust as they regain the strength to swallow again without thinking about it.

“We love helping people,” Hyde Foster said. “I think this is true of all speech therapists — we are helpers by nature.”