Why IDDSI Levels Are Not Permanent

An IDDSI prescription is a clinical decision based on a person’s swallowing function at the time of assessment — it is not a life sentence. Many patients with dysphagia, particularly those recovering from stroke, surgery, or acute illness, will see their swallowing function change over time. Understanding when and how transitions between IDDSI levels happen — and who makes those decisions — is essential knowledge for caregivers, care home staff, and families.

This guide covers both upgrading (progressing to a less restrictive level, e.g. from Level 4 to Level 5) and downgrading (moving to a more restrictive level when swallowing function declines, e.g. in late-stage dementia).

Who Decides When to Transition?

Only a speech-language therapist (SLT) should make the decision to change a patient’s IDDSI level. This is not a decision for caregivers, family members, nurses, or doctors acting without SLT input.

An SLT will:

• Conduct a clinical swallowing evaluation, which may include bedside assessment tools such as the GUSS (Gugging Swallowing Screen)
• In some cases, recommend instrumental assessment such as videofluoroscopic swallowing study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES)
• Review the patient’s overall medical status (e.g. post-stroke recovery trajectory, Parkinson’s progression stage, nutritional state)
• Consult with the dietitian regarding nutritional adequacy at the proposed new level
• Document the revised prescription and communicate it to all relevant care staff

In Hong Kong’s Hospital Authority system, SLT services are available in acute hospitals, rehabilitation hospitals (e.g. Tuen Mun Hospital rehabilitation unit, Shatin Hospital), and some community settings. For patients in residential care homes (RCHEs), access to SLT review can be limited — see Public Hospital Dysphagia Services in HK for referral pathways.

Signs That Suggest a Reassessment for Upgrading

If a patient is consistently performing well at their current IDDSI level, the following signs may indicate that SLT reassessment for potential upgrade is warranted:

Swallowing Function Signs

• No coughing or choking during meals over an extended period (typically several weeks of consistent observation)
• Clear, non-wet voice quality after eating and drinking
• Reduced meal time (less fatigue during eating)
• Improved ability to clear the throat or mouth after swallowing
• Patient reports that swallowing feels easier

Medical and Neurological Recovery Signs

• Positive neurological rehabilitation progress (stroke, brain injury)
• Stable Parkinson’s management with medication optimisation
• Recovery from acute infection or delirium that had temporarily worsened swallowing
• Improved respiratory function (for patients where respiratory weakness was a factor)
• Improved alertness and cognitive engagement with meals

Nutritional Improvement

• Weight stabilisation or gain after a period of decline
• Improved appetite and meal completion rates

Reminder: These signs suggest reassessment is appropriate — not that upgrading should proceed immediately. Contact the SLT.

Signs That Suggest a Downgrade May Be Needed

Swallowing function can worsen, particularly in progressive neurological conditions, during acute illness, or in late-stage frailty. Signs requiring urgent SLT review include:

• New or increased coughing during or after meals
• Wet, gurgly voice quality after eating or drinking (a sign of liquid pooling around the vocal cords)
• Recurrent chest infections or aspiration pneumonia — especially if correlated with mealtimes
• Significantly prolonged meal times — taking more than 30–45 minutes to eat a standard meal
• Food or liquid residue in mouth after swallowing — patient reports feeling food is “stuck”
• Refusal to eat or significant reduction in intake without clear non-swallowing cause
• Choking episodes — even if infrequent

In progressive conditions such as Parkinson’s disease and dementia, periodic review (at least 6-monthly, or sooner if clinical changes occur) is standard best practice.

Transitioning Through Levels: A Practical Framework

Step-by-Step Approach to Upgrading

1. SLT completes reassessment and confirms patient is a candidate for trialling a less restrictive level
2. Supervised trial — patient tries the new level under SLT or trained staff observation, typically with water or a simple food item first
3. Observation period — patient is monitored over several meals (typically 3–5 days) at the new level for any adverse signs
4. Formal review — SLT confirms whether to maintain the new level or return to the previous one
5. Documentation update — all care plans, handover sheets, kitchen instructions, and family communications are updated to reflect the new level

Partial Transitions

Some patients do well with graduated transitions:

• For example, a patient prescribed Level 2 (Mildly Thick) for all liquids might trial Level 1 (Slightly Thick) for warm tea but maintain Level 2 for cold water, if the SLT determines temperature is a factor
• Solid food and liquid levels can sometimes move independently — a patient may progress to Level 6 for solids while remaining at Level 2 for liquids

Temporary Downgrades

Swallowing function frequently worsens temporarily during:

• Chest infections or pneumonia
• Urinary tract infections and other systemic infections in elderly patients
• Increased Parkinson’s medication wearing-off periods
• Periods of reduced consciousness or increased confusion
• Fatigue — swallowing tends to be worse when patients are tired

In these situations, a temporary downgrade may be appropriate and should be reversed when the patient’s condition stabilises. Care staff should flag changes promptly rather than managing independently.

Documentation and Communication During Transitions

A transition is only safe if it is communicated to everyone involved. In Hong Kong care home and home care contexts, this means:

• Updating the care plan and dietary requirements sheet in the resident’s file
• Briefing all care staff — not just the shift that witnessed the assessment
• Informing kitchen or meal preparation staff about the new texture or liquid level
• Notifying family members who may prepare or bring food
• Updating domestic helpers with written instructions

For SeniorDeli platform users, dietary level updates can be reflected in the care food order system to ensure compliant meals are provided automatically. Visit seniordeli.com for more information.

Special Considerations in Hong Kong Settings

Hospital discharge transitions: Patients are often discharged from Hong Kong public hospitals at a transitional stage of recovery. The discharge IDDSI level may not be the final level — follow-up SLT review in the community or outpatient setting is important.

RCHE capacity: Not all residential care homes in Hong Kong have direct access to SLT services. Homes should have a clear protocol for requesting SLT assessment through community outreach or HA outpatient referral when swallowing changes are observed.

Family pressure: Families sometimes pressure caregivers to give “normal” food because the patient appears to be eating well or because they believe the restriction is unnecessary. This is a significant risk factor for aspiration. Families should be educated about why the IDDSI level was prescribed and what the risks of non-compliance are.

Related Resources

• IDDSI Guide Overview
• Post-Stroke Swallowing Recovery
• Understanding SLT Reports
• Speech Therapy Referral in HK

Information on this page is for educational purposes only and does not constitute medical advice. IDDSI dietary levels must be determined by a speech therapist following individual assessment.