New Swallowing Training Program Helps Older Adults Eat and Drink Again Safely

For millions of older adults, the simple act of eating a meal becomes a daily hazard. Age-related dysphagia, a progressive difficulty with swallowing that affects roughly 30 percent of adults over 65, quietly erodes autonomy, nutrition, and quality of life while raising the risk of malnutrition, aspiration pneumonia, frailty, and social isolation. Now, a proof-of-concept study from Danish researchers offers an encouraging signal that a carefully structured, occupation-centred rehabilitation program can help older people reclaim safe and enjoyable mealtimes—right in their own kitchens, care homes, and rehabilitation centres.

The intervention, known as ACTING (ACTivity-based Skill Training of INGestion), was developed by occupational therapists in Denmark and evaluated in a study published in the Scandinavian Journal of Occupational Therapy. Unlike traditional dysphagia treatments that rely on isolated strengthening exercises or texture-modified diets delivered in clinic rooms, ACTING embeds swallowing rehabilitation directly into real meals. Participants practise eating and drinking with actual food and fluids, progressively calibrated to their ability, across authentic mealtime contexts such as breakfast, lunch, and snacks.

Technically, ACTING is grounded in the Person-Environment-Occupation model, the Occupational Therapy Intervention Process Model, Self-Determination Theory, and motor learning theory. This theoretical scaffolding matters: the intervention deliberately balances task-specific skill practice with strategies that support autonomy, competence, and relatedness, the three psychological needs thought to sustain motivation in rehabilitation. Swallowing, after all, is not merely a reflex but a chain of coordinated, goal-directed skills spanning the preoral, oral, and pharyngeal phases of ingestion—from recognizing food and organizing the environment to manipulating the bolus and protecting the airway.

The program’s architecture is strikingly precise. Therapy is delivered individually, twice weekly for up to eight weeks, with a maximum of 16 sessions of up to 60 minutes each. Progression follows a structured 17-level hierarchy of liquid and food textures. A participant’s starting level is determined by the McGill Ingestive Skills Assessment (Danish version), which identifies the most complex texture that can be consumed without clinical signs of aspiration such as coughing, wet voice, or noisy breathing. A higher texture is introduced only when a participant can ingest the current one ten times safely and with reduced perceived exertion, rated on a standard 0-to-10 scale. Safety rules are explicit: if aspiration signs appear in two or more of ten attempts, the task level is downgraded to keep aspiration below 20 percent of attempts.

The proof-of-concept study was originally designed as a one-group pre-post trial with 30 participants, but recruitment proved far harder than anticipated. Over 17 months, 160 individuals were screened and 151 failed to meet inclusion criteria, often due to cognitive impairment, ineligible swallowing-screen scores, or palliative status. Of nine people allocated to the intervention, three died of natural causes before it began, leaving five participants—three men and two women aged 67 to 88—who completed both the program and post-intervention assessments. The results were therefore reported as a case series, an approach suited to early-stage evaluation of complex interventions, though it cannot establish causation.

Despite the tiny sample, the outcomes were notable. All five participants improved their dietary variety, measured on the Functional Oral Intake Scale, advancing by at least one clinically relevant level. Four of five achieved clinically meaningful gains in mealtime task performance on the MISA2DK, with improvements spanning positioning, self-feeding, and ingestion skills. Perceived improvements in eating and drinking were reported by four participants on a Global Rating of Change scale. Secondary outcomes showed encouraging trends: self-reported dysphagia severity improved in most cases, maximum tongue pressure rose meaningfully in three participants, orofacial function improved in four, and dysphagia-related interference with joy of life decreased in four cases. Crucially, there were no adverse events during therapy and no cases of physician-diagnosed aspiration pneumonia during the study period.

One striking finding underscores the multifactorial nature of age-related dysphagia. Participant A demonstrated marked gains in mealtime performance and diet variety despite showing no measurable increase in tongue strength. This dissociation suggests that meaningful improvements in feeding, eating, and swallowing performance can occur even when underlying physiological impairments persist—precisely the premise of occupation-centred rehabilitation, which targets task-level skill rather than isolated muscle function alone. The program uses effortful swallowing manoeuvres, texture progression, and motor-learning principles such as task variation, mixed practice, and realistic intake volumes to drive adaptation.

Yet the study is equally candid about implementation challenges. Direct observation of only 10 of 56 therapy sessions revealed that adherence to the intervention’s 38 core components was high in just 42 percent of observed items and unsatisfactory in another 42 percent, with problems concentrated at session start-up and closing and in the use of effortful swallowing and texture progression. No participant completed all eight weeks; home-practice worksheets were never returned, partly because cognitive limitations hindered participants’ self-monitoring. A focus group with the three treating occupational therapists, analysed through the Theoretical Domains Framework, identified 24 facilitators but also nine barriers, with environmental context and resources dominating. Rigid schedules clashed with mealtime-based delivery, and the frailty of the target group repeatedly complicated participation. Therapists nonetheless reported that ACTING sharpened their occupation-centred professional identity and confidence, shifting practice away from compensatory diet modifications toward retraining eating skills.

The researchers, led by Tina Hansen of Copenhagen University Hospital Amager and Hvidovre and the Parker Institute, conclude that ACTING shows promise as an occupation-centred approach to dysphagia rehabilitation in municipal practice, but that larger effectiveness trials must wait until implementation fidelity and clinician training are strengthened. The study also highlights a broader lesson for ageing societies: with swallowing difficulties entwined with sarcopenia, multimorbidity, and neurogenic change, rehabilitation that treats the meal—not just the swallow—as the unit of therapy may offer older adults something beyond clinical scores: the return of one of life’s most fundamental and social pleasures.

Subject of Research: Occupation-centred rehabilitation of age-related dysphagia in older adults

Article Title: Occupation-centred intervention for age-related dysphagia: A proof-of-concept study

Article References: Hansen, T., Andersen, U., Takeuchi Holm, M., & Wæhrens, E. E. (2025). Occupation-centred intervention for age-related dysphagia: A proof-of-concept study. Scandinavian Journal of Occupational Therapy, 32(1), 1-18. https://doi.org/10.1080/11038128.2026.2620346

Image Credits: AI Generated

DOI: 10.1080/11038128.2026.2620346

Keywords: age-related dysphagia, occupational therapy, ACTING intervention, swallowing rehabilitation, mealtime performance, older adults, presbyphagia, sarcopenic dysphagia, implementation fidelity, motor learning, aspiration pneumonia, rehabilitation