Eating and Swallowing in Dementia: Practical Tips for Families and Carers

In short: Dementia often changes how a person eats and swallows. They may forget to chew or swallow, hold food in the mouth, become easily distracted, or no longer recognise food and utensils. Simple changes to positioning, the eating environment, the way help is given and the timing and size of meals can make mealtimes safer, calmer and more nourishing [1]. If there are signs of choking, coughing or chest infections, a swallowing assessment by a speech therapist is recommended.

Why dementia affects eating and swallowing

Dementia affects the parts of the brain that control attention, memory, recognition and the planning of movement. As a result, eating and swallowing can change in several ways:

• Attention and distraction: the person may stop eating halfway, wander off, or be drawn to noise and movement around them.
• Recognition: they may not recognise food, a cup or a spoon, or may not know what to do with them.
• Planning of movement (apraxia): they may have trouble starting to eat, bringing food to the mouth or using utensils, even when their hands are strong enough.
• Oral holding and pocketing: food may be kept in the mouth for a long time without swallowing, or stored in the cheeks.
• Slower or weaker swallow: especially in the later stages, the swallow may be delayed, so food or drink can go the wrong way (aspiration).
• Changes in appetite and taste: some people prefer sweet foods, eat much less, or refuse food at certain times of the day.

Signs that swallowing may not be safe

• Coughing, choking or throat clearing during or after meals or drinks
• A wet or gurgly voice after swallowing
• Food left in the mouth long after the meal
• Meals taking much longer than before (for example, more than 30–45 minutes)
• Repeated chest infections or pneumonia, or unexplained fever
• Weight loss or reduced intake of food or fluids

If you notice any of these signs, speak to the doctor and arrange a swallowing assessment. The texture of food and drinks should only be changed on the advice of a speech therapist.

Practical strategies for safer, easier mealtimes

1. Get the position right

• Sit the person fully upright, as close to 90 degrees as possible, ideally in a chair at the table rather than in bed.
• Keep the feet flat and supported, and the head upright or slightly tilted forward. Avoid letting the head tip backwards.
• If eating in bed, raise the head of the bed as high as it will go and use pillows to keep the body straight.
• Keep the person upright for at least 30 minutes after eating to reduce the risk of food coming back up.
• The person helping should sit at eye level, in front or slightly to the side. Standing over someone while feeding makes them look upwards, which makes swallowing less safe.

2. Reduce distractions

• Turn off the television and radio, and keep the area quiet and calm.
• Eat in the same familiar place at the same times each day.
• Clear the table of unnecessary items. Put out only the plate, cup and utensils needed.
• Have one person help at a time and avoid many people talking at once.
• Give the meal your full attention. Avoid using the phone while helping.

3. Make food easy to see and recognise

• Use a plain plate in a colour that contrasts with the food and the table, for example a dark plate for rice or porridge.
• Serve one or two foods at a time instead of many dishes, to avoid confusion.
• Tell the person what the food is, and let them see and smell it before eating.
• Familiar, favourite and strongly flavoured foods often encourage eating.

4. Encourage independence with cues

• Use short, simple instructions, one step at a time: “Pick up the spoon.” “Take a small bite.” “Chew.” “Swallow.”
• Show them what to do. Eating alongside them lets them copy your actions.
• Hand-over-hand: place your hand over theirs and gently guide the spoon to their mouth. This helps start the movement when they cannot plan it themselves [2].
• Hand-under-hand: place your hand under theirs so they lead the movement while you support. Many people with dementia find this feels more natural and respectful [2].
• Finger foods such as small sandwiches, soft fruit pieces or kueh can help people who cannot manage utensils, if they are safe for their swallow.
• Adapted cups and cutlery, such as cups with two handles or utensils with thicker grips, may help.

5. Pace the meal

• Offer small mouthfuls. A teaspoon helps to control the amount.
• Wait until the previous mouthful has been swallowed and the mouth is clear before offering the next.
• Give small sips of drink, not big gulps. Avoid straws unless the speech therapist has recommended them.
• Do not rush. Allow plenty of time, and stop if the person is tired, drowsy or coughing.

6. Help with holding food in the mouth

• Gently touch the lips with the spoon to signal that food is coming.
• Use a gentle downward press of the spoon on the middle of the tongue as you offer food.
• Try alternating different tastes, textures or temperatures, such as a warm mouthful followed by a cool one, to prompt a swallow.
• Remind them to swallow with a simple cue, or ask them to swallow again.
• Check the mouth and cheeks for leftover food after the meal.

7. Offer small, frequent meals

• Five or six small meals and snacks a day are often easier than three large meals, especially for people who tire quickly or lose interest.
• Offer food when the person is most alert. For many, this is earlier in the day.
• Use nourishing, energy-dense foods and drinks if intake is low. A dietitian can advise on this.
• Keep track of weight, and of how much is eaten and drunk each day.

8. Look after the mouth

Clean the teeth, dentures, tongue and gums at least twice a day, including for people who are not eating by mouth. Good oral hygiene reduces the number of bacteria that can be breathed into the lungs, and lowers the risk of chest infections [3]. Make sure dentures fit well and are worn for meals.

9. Take care with medication

Some people with dementia find tablets hard to swallow. Do not crush or open tablets or capsules without first checking with the doctor or pharmacist, as some medicines must not be crushed. Ask whether a liquid or different form is available.

Eating in the later stages of dementia

In advanced dementia, eating and swallowing difficulties are common and may gradually increase. The focus often shifts towards comfort, enjoyment and quality of life. Careful hand feeding of small amounts of favourite foods, at a pace the person can manage, is often recommended.

Decisions about feeding tubes in advanced dementia are complex and personal. Research has shown that tube feeding in advanced dementia does not reliably prevent aspiration pneumonia or prolong life [4, 5]. Families are encouraged to discuss the benefits, risks and the person’s own wishes with the doctor and care team, ideally early, as part of advance care planning.

How a speech therapist can help

• Assess swallowing safety, at home or in a nursing home where the person usually eats
• Recommend the safest food and drink textures, using the International Dysphagia Diet Standardisation Initiative (IDDSI) framework [6]
• Arrange an instrumental swallow evaluation (FEES) if a closer look at the swallow is needed
• Train family members, helpers and care staff in positioning, cueing and safe feeding techniques
• Review regularly as needs change over time

If you are caring for someone with dementia who is having difficulty eating or swallowing, contact us to arrange an assessment. Home visits are available across Singapore. See also Adult & Geriatric Home Speech Therapy and Dysphagia (Swallowing Difficulties).

This article provides general information only and does not replace an individual assessment. Every person with dementia is different, so please seek advice specific to your family member.

References

1. Volkert D, Beck AM, Faxén-Irving G, et al. ESPEN guideline on nutrition and hydration in dementia – Update 2024. Clinical Nutrition. 2024;43(6):1599–1626.
2. Batchelor-Murphy MK, McConnell ES, Amella EJ, et al. Experimental comparison of efficacy for three handfeeding techniques in dementia. Journal of the American Geriatrics Society. 2017;65(4):e89–e94.
3. van der Maarel-Wierink CD, Vanobbergen JNO, Bronkhorst EM, Schols JMGA, de Baat C. Oral health care and aspiration pneumonia in frail older people: a systematic literature review. Gerodontology. 2013;30(1):3–9.
4. American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. American Geriatrics Society feeding tubes in advanced dementia position statement. Journal of the American Geriatrics Society. 2014;62(8):1590–1593.
5. Davies N, Barrado-Martín Y, Vickerstaff V, et al. Enteral tube feeding for people with severe dementia. Cochrane Database of Systematic Reviews. 2021;8:CD013503.
6. International Dysphagia Diet Standardisation Initiative (IDDSI). The IDDSI Framework. Available at iddsi.org/framework.