Understanding swallowing changes and how to help

Dementia is not one condition

Dementia is an umbrella term describing several neurological diseases that affect the brain in different ways. Conditions such as Alzheimer’s disease, vascular dementia, Lewy body dementia, and frontotemporal dementia can all affect behaviour, communication, and swallowing.

As dementia progresses, the brain areas responsible for recognising food, coordinating chewing, triggering the swallow reflex, and maintaining attention during meals may become impaired.

This means that eating and drinking difficulties in dementia are neurological and sensory, not simply behavioural or due to lack of cooperation.

Understanding these changes helps carers and families support safe and comfortable eating.

Why swallowing changes in dementia

Eating and swallowing rely heavily on sensory feedback from the mouth and throat.

When we eat, the brain constantly receives information about:

• Taste

• Texture

• Temperature

• The size and weight of food in the mouth

• Whether food remains in the mouth after swallowing

This sensory feedback helps the brain decide when to chew, when to swallow, and how strongly the muscles should contract.

In dementia, several neurological changes occur.

Reduced sensory awareness

Peripheral sensory nerve endings in the mouth become less effective, and central processing in the brain becomes impaired.

As a result, the person may not feel food in the mouth in the same way they used to.

This can lead to:

• Delayed swallow trigger

• Reduced awareness of food remaining in the mouth

• Pocketing food in the cheeks or under the tongue

• Reduced chewing efficiency

• Weaker swallow strength

Because the sensory feedback is reduced or delayed, the brain does not receive clear signals that food is present and ready to be swallowed.

The swallow may therefore occur later than it should, or not occur effectively.

Residue and choking risk

If the brain does not register that food remains in the mouth or throat, food may stay behind after swallowing.

This can cause:

• Oral residue (food left in the mouth)

• Pharyngeal residue (food remaining in the throat)

• Food entering the airway (penetration or aspiration)

• Increased choking risk

In advanced dementia, aspiration can sometimes occur silently, meaning the person may not cough even if food or drink enters the airway.

Changes in taste and sensory preferences

Many people with dementia develop changes in taste perception.

Some individuals may prefer:

• Very sweet foods

• Strong flavours

• Highly seasoned foods

This occurs because the brain’s ability to recognise flavours becomes reduced. Stronger flavours can sometimes help the brain identify the presence of food in the mouth more easily, which may support swallowing.

Enhancing flavour with herbs, spices, sauces, or gravies can therefore be helpful.

Why some people overfill the mouth

A common behaviour seen in dementia is over-stuffing the mouth with food.

This is not usually deliberate.

Because the person does not feel the food clearly in the mouth, they may continue adding more food in an attempt to increase the sensory feedback or weight of food.

This can lead to:

• Large mouthfuls

• Poor chewing

• Increased choking risk

Supporting pacing and offering smaller mouthfuls can help manage this.

Why distractions increase risk

Swallowing requires attention and coordination.

In dementia, the brain’s ability to divide attention becomes reduced.

If the person is:

• Watching television

• Engaging in conversation

• Sitting in a noisy environment

their attention may move away from the swallowing process.

This can interrupt chewing and swallowing coordination, increasing the risk of choking or aspiration.

Reducing distractions during meals helps the brain focus on eating.

Positioning during meals

Body position significantly affects swallowing safety.

Eating in bed or in a reclined position can increase the risk of food entering the airway.

Whenever possible, the person should be:

• Sitting upright

• Well supported

• With the head slightly forward

Remaining upright for a short period after eating can also help reduce swallowing difficulties.

Practical strategies for supporting eating

Offer finger foods when appropriate

Finger foods can help stimulate more senses during eating.

Holding food in the hand provides:

• tactile feedback

• visual cues

• smell stimulation

This sensory input can help the brain recognise food and initiate eating.

Finger foods also support independence and dignity, particularly for people who struggle with cutlery.

Encourage slow pacing

Many people with dementia eat either too quickly or too slowly.

To support pacing:

• Offer small bites

• Allow time between mouthfuls

• Use gentle reminders if needed

If assisting with feeding, using a teaspoon or small fork can help control the amount of food given.

Allow time for sensory processing

Because sensory signals travel more slowly in dementia, the brain may take longer to recognise that food has entered the mouth.

When assisting with feeding, it can sometimes help to leave the spoon in the mouth for a moment before removing it.

This provides additional sensory input and can help trigger the swallow reflex.

Support chewing

Dental problems are common in older adults.

If a person:

• has missing teeth

• does not wear dentures

• has poorly fitting dentures

chewing efficiency will be reduced.

Food may need to be:

• softer

• easier to chew

• moister

Adding sauces, gravies, or liquids can help make foods easier to manage.

Adapt the environment

A calm eating environment helps the brain focus on the task of eating.

Helpful strategies include:

• minimising background noise

• turning off television

• maintaining familiar mealtime routines

• sitting and eating together where possible

Eating is not only nutritional; it is also a social and sensory experience.

When to seek professional advice

Specialist input from a Speech and Language Therapist should be considered if:

• coughing or choking occurs during meals

• eating takes significantly longer than usual

• food remains in the mouth after swallowing

• there is unexplained weight loss

• recurrent chest infections occur

Speech and Language Therapists assess swallowing, eating and drinking skills, and provide personalised advice to improve safety and comfort during meals.

Early support can reduce aspiration risk, support nutrition, and help maintain dignity and quality of life.

A key message for carers and families

Changes in eating and swallowing in dementia are neurological and sensory changes, not stubbornness or refusal.

The brain simply receives and processes information from the mouth differently.

By adapting the environment, pacing, and food presentation, carers can help the brain reconnect with the eating process and support safer swallowing.

Eirini Tsaroucha-Kerr, Speech and Language Therapist, Case Manager.
To discuss your Case Management requirements or request Eirini's C.V, please email casemanagement@circlecm.com or call 0129724145. 

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