27 Nov Nutrition for the person with dementia living at home
Dementia management at home (PDF version)
By Alison Pask, NZ Registered Dietitian
This article offers suggestions to ensure improved nutrition for the person with dementia living at home, however the content does not replace the advice of your own health care team.
Optimum nutrition is essential for everyone, but it’s particularly vital for the health, wellbeing and independence of people living with dementia, says Activity and Nutrition Aotearoa executive director Alison Pask.
Dementia is the name given to a group of symptoms caused by disorders that affect the brain. People with dementia have problems with memory, reasoning and speech, which affect their ability to perform everyday activities. Because dementia can interfere with a person’s ability to prepare, eat and enjoy meals, it can frequently affect food and nutrient intake.
“Globally, the number of people diagnosed with dementia is increasing, with dementia now being recognised as a major health challenge,” Alison says.
Many people with dementia are looked after in the home by whānau, family and caregivers. If you care for someone with dementia, encouraging good eating habits is very important as a healthy diet plays a crucial role in managing the symptoms, from dealing with weight changes before diagnosis to ensuring optimum health as much as possible afterwards.
Catherine Hall, Chief Executive of Alzheimers NZ says “Good nutrition is essential in the care and support of people with dementia. Not only from a nutritional perspective, but also for the wellbeing of people living with dementia.”
Maintain optimal body weight
Dementia may cause weight loss, or in a smaller number of cases excessive weight gain, because of changes in cognitive (brain) function.4,5
Studies show that unintentional weight loss often comes before a diagnosis of dementia.1 Nearly half of people with dementia lose weight unexpectedly before they are diagnosed.2 Maintaining optimum weight and making sure people with dementia are eating well can help reduce the risk of frailty and muscle loss, or in some cases reduce the risk of excessive weight gain, and make it easier for them to participate in everyday life.2,3
Alison says, “Changes in the brain in the areas that control appetite, smell and taste can all cause weight changes and reduced nutrition intake for someone with dementia. As dementia progresses, weight changes may occur because the person may be burning more energy through wandering or agitated behaviour. Later in dementia, nutrient intake and weight can be affected by a change in eating patterns, refusal to eat, forgetting to eat or a swallowing disorder.”
Small, frequent meals and using high energy foods and drinks in-between meals is a vital first step to ensuring adequate nutrition. But do note that drinks close to mealtimes may reduce the desire for eating a meal.
Here’s a few ideas to add nutrition to drinks served between meals:
- Add yoghurt, ice-cream and/or a tablespoon of milk powder to a milkshake
- Make a small fruit smoothie
- Serve frozen yoghurt, iced chocolate or iced coffee on a hot day
- An ice block is a great way to add fluid
- Serve drinks in glasses, mugs or cups that are easy to hold.
Milky desserts like custard, rice pudding, sago, semolina, or mousse can be a great way to add extra energy and protein. These maybe better served after the lighter meal of the day to avoid a person with a small appetite feeling overwhelmed with too many food options.
General tips for preparing and serving food for someone with dementia:
- Serve foods that are familiar, now is not the time to experiment with new flavours, textures or combinations. Serve the person’s favourite foods from childhood, as these are often the foods that are remembered the most fondly.
- Offer more food when the person is most hungry. This maybe in the morning when the person has more energy and is more inclined to eat. Often later in the day a person may lose interest in eating and chewing food becomes tiring.
Texture is important
- Arrange food attractively on the plate, paying special attention to the texture of the food.
- You may need to keep the texture of meals similar for example, an apple crumble maybe better tolerated if the crumble is mixed with the apple rather than served on top and a smooth soup may be better than one with chunks of vegetables.
- Foods that require chewing may need to be cut up, mashed or pureed rather than being served whole. If this is the case keep the foods separate to maintain individual colour and taste.
- Softer, moist foods may be easier to chew than dry foods. These four suggestions are ideas for adding moisture:
- make the most of casseroles and slow-cooked meals
- serve a roast meat with gravy or corned beef with mustard sauce
- add a cheese sauce to vegetables
- serve desserts with custard or yoghurt.
Two serves of fruit each day will add colour, variety and flavour to meals as well as vital nutrition. The fibre from fruit will also help with regular bowel motions.
Constipation maybe an issue that is not routinely considered. Ensuring regular bowel motions can be useful to avoid issues of stomach pain that can impact on food intake. Adequate fibre and fluid intakes, medications and a lack of physical activity can be linked to changed bowel habits. A daily kiwifruit can help prevent constipation.
Cut up fruit so it can be eaten in bite size pieces in the fingers and add tinned or stewed fruit to milky desserts and breakfast cereals.
Offer supper before bed
Food before evening bedtime may help with a settled sleep especially a protein snack e.g. a warm milky drink and/or a small cheese or ham sandwich.
It can be a good idea to have a pre-made snack in the fridge so if the person with dementia wakes during the night you can offer them something to eat without having to make something from scratch.
Appropriate utensils and plates make a difference
- Foods that can be eaten with a spoon or with the fingers may be easier than foods that require a knife and fork.
- If the person is having difficulty using a knife and fork, cut up the food first and offer a spoon. However, avoid limiting the person’s independence, they might prefer to do this for themselves.
- Avoid serving foods that may fall off a spoon or fork, such as a couscous salad.
- The type of dish used can make a difference. Soup served in a cup may be better than in a bowl that requires a spoon. Plates with side edges help with getting the food onto the fork.
- Plates and cups that provide a contrast in colour with the table or placemat can be helpful in recognizing the food and in encouraging independence.
- Establish a routine so the person is familiar with the eating and dining process. Sitting at the same table with the same table setting works best.
- Offering a choice of foods at each meal can be confusing for the person with dementia. However, it remains important that people with dementia do have a choice and this maybe a question such as “Would you like bacon with your eggs?” or “Would you like your eggs fried or poached?”. This type of question allows some choice but also makes it less demanding for the person cooking the meal who has in this case decided to cook eggs. Too many questions can become confusing for the person with dementia, so work out a happy balance and expect this to change as the dementia progresses.
- Turn off distractions such as the TV so the person can concentrate on eating.
- Calming music in the background may help those who are restless (but not always)
- If at a large gathering such as a birthday gathering the occasion may be overwhelming, so don’t get too alarmed if food intake is reduced occasionally
- Starting a task can be more difficult for someone with dementia, so having someone to help them start eating can be beneficial, such as placing the knife and fork in the person’s hands and helping to load the fork.
Allow adequate time for eating
- A person with dementia may become a slow eater so offer to reheat the meal, ensuring a safe temperature is maintained. This can make a significant difference to the enjoyment of the food. Avoid overwhelming the person by serving too much food at once. Serve courses separately. It can appear too much if a person is given soup, main and dessert all at once on the table.
- As a person becomes tired, chewing becomes more difficult so soft, moist foods that require less chewing may be better at the end of the day when fatigue sets in.
- Consider serving the main meal at midday and a lighter meal in the evening, such as a small omelette followed by a milky pudding.
Encourage adequate fluid intake
Someone with dementia may not recognise when they are thirsty, so encourage regular drinks.
- Have a glass of water always available and in sight.
- Use a suitable glass or cup for drinks, something that is easy to use. Check the handle is big enough for larger hands to avoid spills. If easier, serve drinks with a straw but this won’t work for everyone.
- Ice blocks in summer months are great ways to add liquid and coolness on a hot day.
- If the person drinks alcohol, they may lose track of how much they have had and over-consume, so have someone monitor the amount of alcohol poured.
- Avoid giving fluids, especially supplement drinks immediately before mealtimes as they will limit the desire for eating a meal. Drinks in-between meals are important to maintain an adequate fluid intake.
Ensure food is safe
With a decline in cognitive function comes changes in behaviour and memory that may affect the person’s ability to prepare and eat food safely. Often, carers or family pick up that food is being left to waste, the stove hasn’t been turned off or other food-safety issues. A person may also restrict food intake because of a perceived lack of finances.
A person with dementia may:
- Forget to check use-by or best-before dates
- Not recognize that food has spoiled or smells off before eating
- Forget to turn off the elements or oven
- Burn themselves from hot items like piping hot soup or black tea
- Cut themself with sharp knives or graters
- Store food inappropriately e.g. cold food not stored in the fridge.
Encourage physical activity
Keeping active can help maintain muscle strength and reduce the risk of falls. “Physical activity programmes may help maintain activities of daily living but is unclear whether this will help preserve cognitive function,” says Alison. “But we do know that where possible and safe, physical activity should be encouraged.”
Seek professional advice
It’s best to discuss any concerns with the GP and request a referral to the necessary specialists such as a dietitian, as professional assistance can prevent further health complications for the person with dementia. Home support can make a big difference.
Regular nutrition screening is an easy way to identify people with dementia who are at risk of under-nutrition.6
The health professional may recommend a nutritional supplement drink as these have been shown to maintain or improve weight and nutritional status in people with dementia and may also improve cognitive function7. Common nutritional supplement drinks available are: Ensure Plus, Fortisip, Complan and Vitaplan.
Maintain dental health as the person with dementia may not recognise pain, ulcers, decay or ill-fitting dentures.
As dementia progresses, the person with dementia may require feeding, or special equipment that helps them feed themselves.8 In the later stages of dementia swallowing difficulties may occur. This should be investigated if the person coughs when eating, holds food in their mouth and forgets to swallow or regurgitates food.
The caregiver is a vital resource that shouldn’t be overlooked by family and friends. Where possible support the caregiver with meals, help with gardening, invite them for meals and offer social company.
Ten support strategies to consider: 9
- Seek help with shopping and/or cooking
- Arrange groceries to be delivered
- Sign up to meal-delivery services
- Make use of prepared foods where possible e.g. ready-made soups
- Create opportunities to eat with others
- Set reminder to have meals e.g. a phone call
- Encourage small, frequent meals and snacks
- Have easy-to-eat foods at eye level in the fridge
- Encourage food that can be eaten with fingers rather than cutlery
- Home help to help manage medications and daily activities like showering.
Most importantly every person with dementia should be treated as an individual and there is not a one-size-fits-all solution so regular reassessment is required to ensure optimum nutrition.
1 Nutrition and dementia. Published by Alzheimer’s Disease International (ADI), London. February 2014. Reprinted October 2014
2 Volkert, D., Chourdakis, M., Faxen-Irving, G., Frühwald, T., Landi, F., Suominen, M. H., … & Schneider, S. M. (2015). ESPEN guidelines on nutrition in dementia. Clinical nutrition, 34(6), 1052-1073.
3 Nutrition and dementia. Published by Alzheimer’s Disease International (ADI), London. February 2014. Reprinted October 2014
4 Volkert, D., Chourdakis, M., Faxen-Irving, G., Frühwald, T., Landi, F., Suominen, M. H., … & Schneider, S. M. (2015). ESPEN guidelines on nutrition in dementia. Clinical nutrition, 34(6), 1052-1073.
5 Nutrition and dementia. Published by Alzheimer’s Disease International (ADI), London. February 2014. Reprinted October 2014
6 Volkert, D., Chourdakis, M., Faxen-Irving, G., Frühwald, T., Landi, F., Suominen, M. H., … & Schneider, S. M. (2015). ESPEN guidelines on nutrition in dementia. Clinical nutrition, 34(6), 1052-1073.
7 Allen, V. J., Methven, L., & Gosney, M. A. (2013). Use of nutritional complete supplements in older adults with dementia: systematic review and meta-analysis of clinical outcomes. Clinical nutrition, 32(6), 950-957.
8 Nutrition and dementia. Published by Alzheimer’s Disease International (ADI), London. February 2014. Reprinted October 2014
9 Volkert, D., Chourdakis, M., Faxen-Irving, G., Frühwald, T., Landi, F., Suominen, M. H., … & Schneider, S. M. (2015). ESPEN guidelines on nutrition in dementia. Clinical nutrition, 34(6), 1052-1073.