Feeding Someone Who Cannot Feed Themselves

Getting ready

Check the person is ready. Is the person awake, alert and able to swallow safely? If they are very drowsy, newly confused, breathless or unwell, do not push food; call the doctor. Never feed someone who is lying flat or who is not fully awake.

Offer the toilet or a pad change first, and wash hands and face so that the person is comfortable.

Hands, glasses and dentures. Wash their hands, put in dentures that fit and spectacles or hearing aids so they can see and understand. Check the mouth is clean and not sore. Poor dentition, mouth sores or thrush can make eating painful; see oral care for frail older adults.

Pain relief and medicines. If pain affects eating, ask the doctor about timing. Do not crush or mix medicines into food without asking the doctor or pharmacist, since some should not be crushed; see giving medicines safely at home.

Wash your own hands and set out a napkin or cloth.

Positioning

Good positioning prevents choking more than anything else.

• Sit the person fully upright, ideally in a chair at a table, with hips back, feet supported and head slightly forward (chin down towards the chest). If in bed, raise the head of the bed as high as is comfortable, around 80 to 90 degrees, and support with pillows or a backrest; see backrests for sitting up in bed.
• Keep the head in a neutral or slightly forward position, not tilted back.
• Sit at eye level or slightly below, and face the person rather than standing over them. Standing makes them tilt the head back.
• Remain upright for at least 30 minutes after the meal, which reduces reflux and aspiration.
• A person with one-sided weakness after stroke may need to be turned or cued so that food sits on the stronger side of the mouth; follow the therapist's advice; see caring for a parent after a stroke.

Setting the scene

• Eat in a quiet place. Turn off the television. Minimise distractions, because eating requires focus.
• Offer food that looks and smells appetising, in the person's usual dishes and flavours.
• Use a spoon with a small bowl, not a large one, and a cup or beaker suited to the person; see easy grip cutlery guide and eating with tremor or weak grip.
• Place food in front of the person where they can see it, and tell them what it is.
• Sit down. Rushing signals pressure; sitting signals time.

How to feed, step by step

1. Small amounts. About half a teaspoon to a teaspoon at a time. Overfilled spoons lead to coughing. 2. Place the spoon gently on the front of the tongue or lips; do not push it into the mouth, and do not scrape it against the upper teeth or tip the head back. 3. Wait for the swallow. Watch the throat and mouth. Ask the person to swallow, or look for the movement of the voice box. Do not offer the next mouthful until the mouth is empty, and consider a second swallow if the voice sounds wet. 4. Alternate foods and sips as the person likes, offering fluids in small sips with the head neutral. 5. Go at their pace. A meal may take 30 to 45 minutes or more. Pauses to rest are fine. 6. Talk gently, but not when the person has food in the mouth, and avoid questions that require answers while they chew or swallow. 7. Respect refusal. If the person turns their head away, closes their mouth, spits out food or pushes the spoon away, stop. Try again later. Do not force food. 8. Keep the mouth clean during and after the meal, and check for pocketed food in the cheeks, which can cause choking later. 9. Offer fluids regularly unless restricted, in sips throughout the day; see hydration for older adults. 10. Allow the person to do what they can, such as holding the cup or finger foods, to maintain skill and dignity.

Food textures and fluids

If swallowing is a problem, a speech and language therapist will recommend the safe texture of food (soft, minced and moist, pureed) and sometimes thickened drinks. Follow it exactly. Do not guess. General notes:

• Avoid dry, crumbly, sticky or mixed-texture foods such as dry rotis, biscuits, nuts, chewy meat, whole grapes, raw vegetables and rice with thin watery dal if the therapist has said to avoid them.
• Moist, cohesive foods, such as soft khichdi, mashed banana, curd rice, soft idli with chutney or sambar, porridge, mashed potato or pureed vegetables, are often easier, but the therapist decides what suits your parent.
• Do not thicken drinks with powder or starch unless advised on the type and thickness; the wrong thickness is unsafe.
• See soft and pureed diets and swallowing problems and dysphagia.

Warning signs of swallowing trouble

Report these to the doctor, and ask for a swallowing assessment:

• coughing or choking during or after eating or drinking;
• a wet, gurgly or hoarse voice after swallowing;
• food or drink coming out of the nose or mouth;
• holding food in the mouth, slow chewing or pocketing;
• repeated chest infections or fever without clear cause;
• weight loss, avoiding certain foods, or refusing meals;
• breathlessness or watery eyes while eating.

Silent aspiration, where food enters the lungs without coughing, can occur. Chest infections and fever after meals should be taken seriously; see aspiration pneumonia prevention and pneumonia prevention and recovery in seniors.

If the person chokes

• If they can cough, speak or breathe, encourage them to keep coughing and stay with them. Do not slap the back while they are still breathing and coughing effectively; do not give water.
• If they cannot breathe, cough or speak, or turn blue, or go silent, call 112 immediately. Ask someone to call while you act. Ask a doctor or first aid trainer in advance to teach you the current first-aid steps for choking in adults, including back blows and abdominal thrusts, since methods differ for frail or bed-bound people and must be learned hands-on. Do not attempt a blind finger sweep.
• After any serious choking episode, even if it resolves, tell the doctor, because the person may have inhaled food.

Eating with dementia

People with dementia may forget to eat, lose the ability to use cutlery, be easily distracted, refuse food, hoard food in the mouth or lose their sense of hunger and thirst.

• Keep the routine and place the same each day; use plain plates in a contrasting colour to the table.
• Offer one food at a time, and finger foods if cutlery is hard.
• Show the action: hold the spoon, then guide the hand with yours, hand-over-hand, instead of taking over.
• Use simple cues and calm music; avoid arguing.
• Offer preferred foods and favourite tastes, and small, frequent meals.
• Watch for pain, poor teeth, constipation or medicines that reduce appetite.
• Accept that appetite and weight may fall in later stages; discuss goals with the doctor; see dementia, eating and weight loss and feeding and nutrition in dementia.

Nutrition and monitoring

Weigh the person every week or two if possible, and note intake in the care diary. Offer protein and energy at each meal, and ask the doctor or dietician about supplements; see malnutrition in older adults and how much protein do seniors need. Do not restrict food for weight loss in a frail person. For diabetes, kidney or heart disease, ask for tailored advice; see nutrition for diabetes after 60.

Dignity

Speak to the person, not over their head. Use a napkin rather than a bib where possible. Offer choices: "Would you like dal or curd first?" Clean the face gently after the meal. Avoid talking about the person as though they are not present. See dignity and consent in care.

Looking after yourself

Feeding can take much of your day. Share the task, use pauses well and ask for training. Back strain can come from bending over a bed; adjust the bed height; see caregiver burnout signs and prevention.

When to ask a professional

A speech and language therapist assesses swallowing and recommends textures. A doctor looks for medical causes of feeding problems, weight loss and chest infection. A dietician helps with nutrition. A nurse can show feeding technique and tube care. For choking, blue lips, severe breathlessness or collapse, call 112.