By Harriet Smith, Registered Dietitian 

This article, which coincides with Dementia Awareness Week (15th-21st May 2020) provides an overview of Alzheimer’s disease, including common nutritional challenges for patients.

Introduction:

Alzheimer’s disease (often referred to as ‘Alzheimer’s) is a progressive and irreversible brain condition that slowly destroys memory and thinking skills. It affects around 500,000 people in the UK (1).  

Alzheimer’s is the most common form of dementia in the UK; accounting for two-thirds of all cases. Dementia is a syndrome that describes a set of symptoms that affect cognitive functioning. These symptoms include memory loss, confusion, changes in mood and difficulty thinking or concentrating (2).

The exact cause of Alzheimer’s is unknown, however, changes occur in the brain, including the accumulation of two proteins called amyloid and tau. These proteins can build-up in the brain many years before symptoms appear (3).

Certain factors are thought to increase a person’s risk of developing Alzheimer’s. These include (4):

• Increasing age
• Family history
• Physical inactivity
• Hypertension
• Obesity
• Smoking
• Social isolation

Signs and Symptoms

The onset of symptoms can appear gradually and usually worsen over time. Initially, a patient may present with mild memory loss and confusion. For example, they may forget names of people, places or objects. Or they may struggle to recall events or repeatedly ask the same question.

As the condition worsens, memory problems can become more severe. They may develop additional symptoms, such as disorientation, getting lost, changes in mood or personality, anxiety, agitation, depression and low mood or problems moving around and performing self-care.

Nutritional Challenges 

Some patients may need assistance with eating and drinking. This can be for a number of reasons, some of which we’ll explore below.

Memory and confusion

In the early stages of dementia, individuals may have problems with shopping, storing and preparing food. Some people may forget whether they have already eaten and they may become incapable of planning, preparing and cooking meals. As dementia progresses, nutritional intake may become inadequate (5).

Problems with swallowing/chewing

Alzheimer’s patients may struggle with the physical aspects of eating and drinking due to swallow problems (dysphagia) or difficulty chewing (6). These patients may require a texture-modified diet which is an appropriate consistency for them to swallow and chew. Commercial thickening agents may be prescribed for patients with dysphagia to improve swallow control and prevent swallow aspiration (7).

Easily distracted whilst eating

Patients may become easily distracted whilst eating, which could reduce food intake.  

Changing the mealtime environment and increasing staff interaction with Alzheimer’s patients has been associated with increased weight gain in a small study of 33 patients on a long-term care ward for Alzheimer’s (8).

The following suggestions may be useful for creating a suitable mealtime environment:

• Encourage patients/residents to sit together
• Model normal eating behaviours
• Increase staff interaction (i.e. chat with residents and eat with them, where appropriate)
• Ensure patients have everything they need (i.e. suitable cutlery, dentures etc.) before eating
• Offer a home-style mealtime service (i.e. eat on tables as opposed to trays)
• Consider suitable lighting and relaxing background music

Changes in food preferences

Alzheimer’s patients may experience a change in food preferences, especially cravings for unhealthy or sweet foods. Small-scale studies have suggested that this could be due to abnormalities in the brain serotonin system, however further research is required (9).

Alzheimer’s patients with aphasia (difficulties with language and speech) may find it difficult to communicate food and mealtime preferences. Including family, friends and carers in food decisions is an important aspect of patient-centered care in patients who are unable to communicate their needs.

Difficulty using cutlery or utensils

Some people with dementia sometimes find cutlery and crockery problematic. Several hospitals and care homes have tested pilot schemes where patients are offered finger foods that can be easily eaten with hands instead of cutlery (10). Finger foods should be robust, easy to hold by the fingers and consumable in one or two bites (11).

Suitable finger food options may include:

• Toast/crumpet fingers
• Mini sausages
• Cubes of cheese and grapes
• Chunks of fruit
• Mini sandwiches
• Vegetable batons
• Cheese straws/breadsticks
• Small scones/biscuits

The Alzheimer’s Society has tested a range of cutlery, crockery and glassware designed to help with eating and drinking in people with dementia. You can read more here.

Malnutrition

The prevalence of malnutrition is high amongst Alzheimer’s patients (12). Someone with Alzheimer’s disease may have reduced food intake and/or poor appetite for a number of reasons, including:

• Memory loss and confusion; patients may not remember to eat and drink or may be unable to recognise hunger cues. Individuals may benefit from verbal cues to remind them to eat.
• Depression; low mood and depression is common in people with dementia (13). Depression has been associated with malnutrition in elderly people (14).
• Medication; certain medicines may affect appetite. ESPEN Guidelines on Nutrition in Dementia recommend “elimination of potential causes of malnutrition as far as possible”/ This includes reduction or replacement of medications with adverse side effects on food intake (15).
• Constipation; this is a common problem in older people. It can lead to nausea, which may affect appetite (16).

ESPEN Guidelines on Nutrition in Dementia recommend that all dementia patients are regularly screened for malnutrition. Patients with or at risk of malnutrition may benefit from oral nutrition support (15). This may include oral nutrition supplements (ONS), dietetic counselling and/or a food-first approach. This is a simple way of delivering extra nourishment to those with or at risk of malnutrition.

You could try offering smaller potions, extra snacks or finger foods and nourishing drinks. Food fortification techniques could also be used to increase the nutritional density of the diet without increasing the volume of food consumed.

Useful Resources:

ESPEN Guidelines on Nutrition in Dementia

The European Society for Clinical Nutrition and Metabolism (ESPEN) has provided evidence-based guidelines on nutrition in dementia. Read more here.  

Eating and Drinking Well: Supporting People Living with Dementia workbook and training film

Based on the findings of a two-year research project, Professor Murphy, Dr Holmes and their team at Bournemouth University has developed a toolkit to provide freely available resources (a film, workbook, leaflet and guide) to deliver person-centred nutritional care in the area of dementia. You can download the workbook, complete the quiz and download a CPD certificate for your portfolio here.

Eating and Drinking Advice from the Alzheimer’s Society

You can read more about dementia and nutritional challenges here.