The behavior of holding food in the mouth without swallowing, often described as “pocketing,” is a common and challenging issue for caregivers of individuals living with dementia. This action involves retaining food in the space between the cheek and the gums or under the tongue, instead of initiating the swallow reflex. The persistence of this behavior can lead to serious health complications like choking, aspiration pneumonia, and poor nutrition. Understanding why this happens requires looking at the complex neurological, sensory, and physical changes that occur as dementia progresses.
Cognitive and Sensory Processing Changes
Dementia directly affects the brain regions responsible for the complex, learned sequence of eating, leading to a breakdown known as oral apraxia. This motor planning disorder means the individual understands the goal of eating but cannot execute necessary muscle movements, such as moving the tongue to form the food bolus. The patient may chew indefinitely or hold the food because the brain fails to signal the next step: propelling the food backward to trigger the involuntary swallowing phase.
Working memory failure is another neurological factor contributing to food pocketing. The memory required to hold information about the food in the mouth and the awareness of the need to swallow can be compromised. The individual may simply forget the food is present or lose the cognitive ability to initiate the effective strategy needed to clear the mouth.
Deterioration of the olfactory and gustatory systems also alters the sensory experience of eating. The sense of taste and smell often diminishes with dementia, making food less appealing. This sometimes causes patients to prefer intensely flavored items, such as those that are very sweet or salty. This change in perception can lead to a reluctance to move the food around or swallow it, especially if the texture or flavor is not stimulating enough.
The ability to accurately gauge the temperature of food can also become impaired due to these sensory changes. If the food is perceived as too hot or too cold, the patient may hold it static in the mouth to avoid discomfort or pain. This sensory processing difficulty, combined with motor planning deficits, contributes to the overall confusion about what to do with the food once it is in the oral cavity.
Physical and Oral Health Factors
Beyond neurological issues, physical and mechanical problems often cause food pocketing, as the patient attempts to avoid pain or difficulty during the swallow. Dysphagia, or difficulty swallowing, is common in the later stages of dementia, affecting over half of all Alzheimer’s patients. Discomfort associated with a painful or labored swallow can instinctively cause the patient to hold the food in the cheek to delay or prevent swallowing.
Oral health issues provide a direct physical reason for avoiding chewing and swallowing. Conditions like ill-fitting dentures, mouth sores, gum disease, or dental caries make mastication painful. This prompts the patient to shift the food to a less sensitive area of the mouth, where the pocketed food may be forgotten or held to avoid further pain.
A lack of saliva, often a side effect of various medications used to manage dementia symptoms, creates difficulty in forming the food into a smooth, cohesive bolus. Dry food particles are harder to manipulate and move toward the throat, which increases the risk of choking and aspiration. This mechanical challenge encourages the patient to hold the dry, unformed food in the mouth, leading to pocketing.
It is important to address these physical factors first, as dental pain and treatable infections can be quickly resolved, potentially alleviating the pocketing behavior. A thorough examination by a dentist or a speech-language pathologist specializing in swallowing disorders can help identify whether the underlying cause is mechanical, painful, or related to the swallow reflex.
Caregiver Strategies for Safer Mealtimes
Caregivers can implement several strategies to mitigate the risks associated with food pocketing, starting with modifications to the meal environment. To help the individual focus their attention solely on eating, reduce noise, clutter, and visual distractions. Serving food on plates that contrast in color with the food and the table surface can also help the patient recognize the meal and its boundaries.
Modifying the food texture can significantly reduce the effort required for chewing and bolus formation. Switching to soft, moist, or pureed foods, or using thickening agents for liquids, makes the food easier and safer to swallow. Offer small, manageable, bite-sized portions to reduce the amount of food the patient must process, minimizing the opportunity for pocketing.
Establishing a slower, more deliberate pace for the meal is essential, ensuring the mouth is completely clear before the next bite is offered. Caregivers should use simple, encouraging verbal cues, such as “Chew now” or “Time to swallow,” to prompt the learned eating sequence. Physical support, like gently placing a hand over the patient’s to guide the utensil, can also help initiate the feeding motion.
After the meal, a meticulous post-meal check is necessary to ensure no food residue remains pocketed, which is a primary risk for infection or aspiration. The caregiver should gently check both sides of the cheek and the area under the tongue. Maintaining excellent oral hygiene, including brushing the teeth after every meal, is a crucial final step to remove lingering food particles.