Alzheimer’s is the most common form of dementia.¹ In support of the recent World Alzheimer’s Month this article helps to raise awareness by exploring the challenges of, and strategies for, eating with dementia.
Dementia describes the symptoms associated with memory loss and difficulties with thinking, problem-solving or language.¹ During the early stages of dementia, approximately 50% of people have difficulties eating, and during the advanced stages of the disease, most people will experience feeding difficulties.² The causes of feeding difficulties are multifaceted and include compromised motor and visual skills, dysphagia and depression.²
Nutrition screening and assessment
Weight loss and malnutrition are commonly seen in people with dementia; early identification of weight loss through nutritional screening is an important aspect of dementia care.³ The Malnutrition Universal Screening Tool (MUST) is a screening tool commonly used in nursing homes to help identify risk of malnutrition.⁴˒⁵ Timely dietetic assessment and treatment can help to improve and maintain nutritional status.⁴˒⁵
Assessment of functional ability
Mealtime observations are essential to identify individuals with reduced functional ability, dysphagia or aversive behaviours. Carers of people with dementia should be given adequate training to help identify any changes.³˒⁵ A referral should be made to a speech and language therapist (SALT) if there are concerns regarding a person's ability to chew and swallow food safely.⁶ Effective mealtime support can include:⁵˒⁷
- Specialist cutlery and crockery e.g., anti-spill cups, suction plates and large cutlery.
- Food texture modification. Pureed or soft foods can help overcome difficulties with chewing and swallowing; recommendations from a SALT should be followed.
- The use of contrasting plain colours. This can help to provide a visual contrast between food and the plate e.g., a blue plate on a white tablecloth.
- Calm lighting and music can reduce distractions and induce positive memories, which can help to minimise agitation.
- Serving a combination of colours on the plate to make food look attractive, as we eat with our eyes too. Aim to serve 3-4 coloured foods on the plate.
- The use of finger foods. These are easy to hold and can be useful when cutlery and crockery are problematic. They can be useful for people who are unable to sit still or who prefer to walk around. Placing trays or plates of finger foods around the house can act as a reminder to eat.
Meeting protein requirements in patients with dementia
To preserve muscle mass and function, it is recommended that older adults achieve 1-1.2g/kg protein per day.⁸ Feeding difficulties in dementia can make this difficult to achieve. A ‘food first’ approach is recommended to increase energy and protein intake. ⁵˒⁶
Food first methods for a patient with dementia may include:⁶˒⁷
- Serve nourishing drinks (e.g., fortified milk, hot chocolate, or malted milk) in a suitable cup e.g., an anti-spill cup
- Offering high energy snacks as finger foods (e.g., sausage rolls, mini sandwiches, pizza fingers) between meals
- Fortifying meals with energy dense foods (e.g., cheese, cream, olive oil)
- Reminding patients to eat little and often; offer a meal or snack every 2-3 hours
If nutritional requirements cannot be met via diet alone, a trial of high-energy, high protein (>20% energy from protein) oral nutritional supplements (ONS) are recommended.⁵
A recent systematic review found that interventions using ONS increased the nutritional intake of older adults with dementia from ~200 to 600 kcal/day, with no negative impacts on food intake. Nutritional status was found to improve, however cognition remained unchanged.⁹ ONS are available in a variety of flavours and compact volumes which can be useful in optimising protein intake in this vulnerable cohort.
Making mealtimes appealing for adults with dementia
To encourage nutritional intake, mealtimes should be a positive and social experience. Here are some top tips for making mealtimes easy, effective, and exciting for people living with dementia: ⁷˒¹⁰
- A combination of different textures is appealing. For adults without swallowing difficulties, aim to offer a variety of crisp, crunchy, chewy, smooth, and soft foods at each meal.
- Modelling —Having people without dementia sitting down to eat alongside adults with dementia can act as a helpful cue for eating and using cutlery.
- Communal settings — Eating with others increases food intake at mealtimes.¹¹
- The smell of fresh food being prepared may induce appetite. Strong smelling foods may even evoke happy memories.
- Stock a variety of pre-prepared meals to use during the day. Home delivery meal services can help to remind and encourage people with dementia to eat and relieve the burden of meal preparation.
- Allow the person with dementia to make decisions on what they prefer to eat, even if the food combinations seem unusual or different to what they previously liked.
- Some commercial food companies have produced historical food packaging. Old food branding has been found to bring back memories from a happy time and helps to positively engage people with dementia at mealtimes.
Evidence has shown that an overarching aspect of delivering nutritional care for people living with dementia is having a person-centred approach.¹² The traditional ‘three meals a day’ approach should be replaced by adapting patients’ food intake in response to their activity behaviours (e.g., wandering), taste changes, functional ability and sleep patterns. People with dementia should have access to appealing foods which are easy to consume (finger foods) alongside adequate support during mealtimes (e.g., verbal cues and positive reinforcement). Mealtime observations and nutritional screening are important to identify those at risk of malnutrition as dementia continues to progress.
A multidisciplinary team approach (involving the GP, dietitian and speech and language therapist) can help to optimise nutritional intake via food fortification methods, ONS and dietary texture modification, alongside the management of symptoms (constipation, oral thrush and depression) which act as barriers to food intake.⁶ Dementia is a progressive disease, therefore frequent monitoring and observation by carers is essential to maintain an effective person-centred nutritional care plan.
- The Alzheimers Society. What is dementia? 2021. [Internet]. Available from: https://www.alzheimers.org.uk/about-dementia/types-dementia/what-dementia
- Chang C, et al. Prevalence and factors associated with food intake difficulties among residents with dementia. PLoS One. 2017; 12(2): e0171770.
- Paul S. Strategies for home nutritional support in dementia care and its relevance in low-middle-income countries. Journal of Family Medicine and Primary Care. 2020; 9(1): 43-48.
- NICE. Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition: CG32. 2017. [Internet]. Available from: https://www.nice.org.uk/guidance/cg32/chapter/1-Guidance#screening-for-malnutrition-and-the-risk-of-malnutrition-in-hospital-and-the-community
Volkert D, et al. ESPEN guidelines on nutrition in dementia. Clinical Nutrition. 2015; 34(6): 1052-1073.
- BDA. Nutrition and Dementia. 2018. [Internet]. Available from: https://www.bda.uk.com/resource/nutrition-and-dementia.html
- Ageing and dementia research centre. Eating and drinking well with dementia. 2019. [Internet]. Available from: https://www.ageuk.org.uk/bp-assets/contentassets/2d42698f64294f3993e75b378eb3292a/eating-and-drinking-well-carers-guide.pdf
- Deutz N, et al. Protein intake and exercise for optimal muscle function with aging: recommendations from the ESPEN Expert Group. Clinical Nutrition. 2014; 33(6): 929-36.
- Tangvik R, et al. Effects of oral nutrition supplements in persons with dementia: A systematic review. Geriatric Nursing. 2012; 42(1): 117-123.
- The Caroline Walker Trust. Supporting Older People and Older People with Dementia. 2014. [Internet]. Available from: https://www.cwt.org.uk/wp-content/uploads/2014/07/EW-Old-Dementia-Practical-Resource.pdf
- Charras K, Fremontier M. Sharing meals with institutionalized people with dementia: a natural experiment. Journal of Gerontological Social Work. 2010. [Internet]. Available from: doi: 10.1080/01634372.2010.489936
- Murphy J, Holmes J, Brooks C. Nutrition and dementia care: developing an evidence-based model for nutritional care in nursing homes. BMC Geriatrics. 2017. [Internet]. Available from: doi: 10.1186/s12877-017-0443-2