Dysphagia Knowledge Hub — 吞嚥困難知識庫

EAT-10 Dysphagia Screening: How to Use It in Care Home Settings

The EAT-10 (Eating Assessment Tool — 10 items) is a brief, validated questionnaire that helps identify people at risk of dysphagia (swallowing difficulty). It was developed by Belafsky and colleagues at the University of California, Davis, published in 2008 in Annals of Otology, Rhinology & Laryngology, and has since been translated and validated in over 20 languages including Traditional Chinese (繁體中文).

In a care home context, EAT-10 serves a specific and important purpose: it gives nursing staff a structured, evidence-based tool to identify residents who need referral to a Speech-Language Pathologist (SLP) — without requiring clinical expertise to administer. It is not a diagnostic instrument, but it is one of the most efficient screening tools available for the care home setting.

1. What EAT-10 Screens For

EAT-10 screens for self-reported or proxy-reported swallowing symptoms across three domains:

For residents who cannot self-report (advanced dementia, significant cognitive impairment), a caregiver or nursing staff member who knows the resident well can complete the tool as a proxy respondent, answering on the resident’s behalf based on observed behaviour during meals. Proxy administration has been validated in dementia populations.

2. The 10 Questions

The EAT-10 consists of 10 questions, each rated on a 5-point scale:

Rating Meaning
0 No problem
1 Mild problem
2 Moderate problem
3 Severe problem
4 Severe problem — this is a major concern

The 10 questions are:

# Question
1 My swallowing problem has caused me to lose weight
2 My swallowing problem interferes with my ability to go out for meals
3 Swallowing liquids takes extra effort
4 Swallowing solids takes extra effort
5 Swallowing pills takes extra effort
6 Swallowing is painful
7 The pleasure of eating is affected by my swallowing
8 When I swallow, food sticks in my throat
9 I cough when I eat
10 Swallowing is stressful

The EAT-10 is reproduced widely and is freely available at iddsi.org and nestlehealthscience.com. It is available in Traditional Chinese from Nestlé Health Science and HKSSHT.

3. Scoring and Interpretation

Scoring: Add the ratings for all 10 questions. Maximum possible score = 40.

3.1 The clinical cutoff

The EAT-10 cutoff validated in the original 2008 study is:

Score of 3 or above = abnormal = refer to SLP

This cutoff was selected to maximise sensitivity (capture most true dysphagia cases) while maintaining adequate specificity (minimise over-referral). At a cutoff of 3, the tool demonstrates:

A score of 0–2 is considered within normal limits, though a score of 1–2 with clinical red flags (e.g., recurrent chest infections, unexplained weight loss) should still prompt clinical judgment about referral.

3.2 Score interpretation table

Score Interpretation Action
0 No identified swallowing concern No action — re-screen annually or on status change
1–2 Below cutoff — borderline Monitor; re-screen in 1–3 months if any risk factors present
3–14 Above cutoff — mild to moderate concern Refer to SLP for formal assessment
15–29 Above cutoff — moderate to severe concern Urgent SLP referral; consider texture/fluid precautions pending assessment
30–40 Severe swallowing concern Same-day or next-day SLP contact; implement immediate safety precautions

3.3 Score does not determine IDDSI level

A critical point for care home nurses: the EAT-10 score does not tell you what IDDSI level to prescribe. It tells you whether a problem likely exists. The IDDSI prescription must come from a formal clinical assessment by an SLP.

Some care homes incorrectly use high EAT-10 scores to justify prescribing a particular texture level. This is a misuse of the tool and may lead to over-restriction of diet (which causes malnutrition and loss of quality of life) or under-restriction (which causes aspiration risk).

4. How to Administer EAT-10 in a Care Home

4.1 When to screen

Administer EAT-10 at:

4.2 Who administers it

Any trained care staff member can administer EAT-10. Training requirement: 15–30 minutes. The staff member must be able to:

4.3 Administration format

Self-report (preferred): Provide the printed form to the resident and allow them to complete it independently. Staff should be present to answer questions about the meaning of items but should not suggest ratings.

Interview format: For residents with literacy difficulty, visual impairment, or mild cognitive impairment, the staff member reads each question and records the resident’s verbal response.

Proxy format: For residents who cannot communicate reliably (e.g., severe dementia), a family member or care worker who observes the resident’s meals answers the questions. Indicate on the form that proxy completion was used.

4.4 Time required

4.5 Documentation

Record the following in the resident care record:

5. When to Refer to SLP: Beyond EAT-10

EAT-10 is one input into the referral decision. The following additional clinical red flags should prompt SLP referral regardless of EAT-10 score:

Red flags requiring SLP referral

Red Flag Why It Matters
Recurrent chest infections or pneumonia (2+ in 12 months) May indicate silent aspiration
Unexplained weight loss (>5% in 3 months) May indicate reduced intake due to swallowing difficulty
Coughing or choking during/after meals, observed by staff Overt aspiration sign
Wet or gurgly voice quality during or after eating Fluid on vocal cords — possible pharyngeal aspiration
Food or fluid visible in tracheostomy secretions Direct evidence of aspiration
History of stroke (recent or past) Even if currently asymptomatic
Parkinson’s disease Pharyngeal dysphagia develops progressively
Dementia (moderate to severe stage) Feeding behaviours change; aspiration risk increases
New head and neck surgery or radiation Structural and neurological changes affect swallowing
Prolonged intubation (>48 hours) post-hospitalisation Post-extubation dysphagia is common

6. After Referral — What Happens Next

Understanding the SLP assessment pathway helps care home staff set appropriate expectations for residents and families.

6.1 Clinical Swallowing Examination (CSE)

The SLP will conduct a bedside Clinical Swallowing Examination (CSE), also called a Clinical Swallowing Assessment (CSA). This involves:

The CSE typically takes 30–60 minutes.

6.2 Instrumental assessment

If the CSE indicates risk but does not provide sufficient information about the degree of aspiration, the SLP may refer for instrumental assessment:

6.3 SLP report and recommendations

Following assessment, the SLP will provide a written report specifying:

This report drives the resident’s care plan update and kitchen meal order changes.

7. Limitations of EAT-10

EAT-10 is a well-validated tool, but care home staff must understand its limitations:

7.1 It misses silent aspiration

Silent aspiration — food or fluid entering the airway without triggering a cough response — occurs in up to 40% of people with dysphagia. Because EAT-10 asks about experienced symptoms, a resident who silently aspirates may score below the cutoff. Residents with brainstem stroke, advanced dementia, or reduced laryngeal sensitivity are at highest risk of false-negative EAT-10 results.

Implication: EAT-10 screening does not replace clinical judgment. Residents with silent aspiration risk factors (conditions listed above) should have SLP assessment even if EAT-10 score is normal.

7.2 Cognitive impairment limits self-report validity

For residents with moderate to severe dementia, self-report is unreliable. Proxy completion partially addresses this, but proxy reporters may underestimate symptoms they cannot directly observe (e.g., feeling of food sticking in the throat).

7.3 It does not differentiate oropharyngeal from esophageal dysphagia

EAT-10 detects swallowing symptoms but cannot localise the problem. Esophageal dysphagia (e.g., from reflux, stricture, or achalasia) requires different investigation and management. An SLP can help differentiate — but a gastroenterology referral may be necessary.

7.4 Scores may fluctuate with non-dysphagia factors

Scores may be elevated during acute illness (dental pain, sore throat, oral ulcers) and return to normal without representing true dysphagia. Re-screen after acute illness resolves if score was elevated.

8. EAT-10 in the Broader Screening Ecosystem

EAT-10 pairs well with other screening and monitoring tools:

Tool Purpose Used by
EAT-10 Symptom-based screen; identifies need for SLP referral Nurses, care staff
GUSS (Gugging Swallowing Screen) Bedside water + food swallow test; more clinical Trained nurses, medical staff
Oral Health Assessment Tool (OHAT) Oral hygiene screening Nurses, dental staff
MNA-SF (Mini Nutritional Assessment Short Form) Malnutrition risk Nurses, dietitians
Weight monitoring (monthly for high-risk residents) Detects nutritional decline All care staff

A comprehensive dysphagia surveillance system in a care home uses all of these tools in combination, with clear escalation pathways linking each to clinical assessment and management.

9. Free EAT-10 Resources

The EAT-10 is in the public domain and freely available:

Care homes may reproduce and use EAT-10 freely for clinical purposes without royalty. For publication in research, cite the original Belafsky et al. (2008) paper.

Summary

EAT-10 is a 10-item, 2-minute questionnaire that is one of the most practical dysphagia screening tools available for care homes. A score of 3 or above triggers SLP referral. It can be completed by the resident, by interview, or by a proxy caregiver. It does not replace clinical assessment, cannot detect silent aspiration reliably, and does not determine IDDSI levels — but it dramatically improves the systematic identification of residents who need SLP input, and in a care home population where dysphagia prevalence is 30–40%, systematic screening is essential.

Author: SeniorDeli (Carewells) — [email protected]

Licensed under CC BY 4.0. You are free to share and adapt this material with attribution.