By Helen Rasmussen, M.S., R.D., F.A.D.A.

Where there’s dementia, there are nutrition and feeding challenges. Here are some thoughtful, sensible, and respectful ways to conquer them.

Those with Alzheimer’s disease and other causes of dementia frequently become malnourished as their interest in eating and feeling of hunger diminish.

Employing the elements of DINE™—Dignity, Independence, Nutrition, and Environment—will go a long way to help you manage nutritional needs for a loved one with dementia.

Dignity

Those of us who are entrusted to care for another are in a unique position to convey genuine respect for our loved one, for the person we remember from better says as well as the person he or she has now become. Every day we should make thoughtful choices that incorporate the preferences and needs, and reflect the irreplaceable value, of the person in our care. Keeping the following in mind can help your loved one retain dignity.

Early phases of dementia include problems with memory and judgment. Recognize that difficulties with shopping, preparing and storing food can make people feel less dignified and more vulnerable. However, when you make mealtimes important, you enable a person to preserve a sense of self worth.

When you help maintain the person’s meal habits, religious rituals and special dietary preferences you provide structure, comfort and connections to the patient’s fragile sense of identity.

Note: Whenever you feel frustrated or discouraged, it may sometimes be necessary to remind yourself of how your loved one once was the head of the family, providing nourishment and stability now no longer possible, or of other life contributions the person has made.

Independence

Maintaining independence is a basic human need and it often falls on the caregiver to find ways of promoting autonomy as eating abilities and interests in food change, sometimes even over the course of a meal. For example, a person may appear to be eating independently at the start of a meal but then you notice that he is unable to finish the meal unassisted. This signals the need to create new mealtime strategies. The following suggestions may make the task of eating more palatable:

• Avoid putting too many food items or large portions on one plate.
• Pre-cut food into bite size pieces before serving.
• Initially, offer some liquids to moisten the mouth to prepare the person for eating. This will lubricate a dry mouth or stimulate saliva and gastric juices to make the person more interested in eating. It’s also a safer way to begin a meal than starting with whole food or food particles.
• Encourage independence and reinforce the motion of self-feeding by offering finger foods. Examples of finger food are tuna, egg or chicken salad sandwiches, slices of cheese, sections of oranges. Such easy-to-eat and nourishing foods can also help slow weight loss.
• Invest in self-feeding devices. Providing feeding appliances for a person creates a simple way to maintain access to food. (A list of suppliers of daily living aids is at the end of this article.)

Nutrition

Caregivers need to present food choices with the express purpose of fitting as many nutrients as possible into the calories consumed.

With respect to the particular nutrient needs of this vulnerable population, the Tufts University Modified Food Guide Pyramid for People Over 70 (Shown at right) is an ideal guide for caregivers to adopt. It suggests providing less food at the base of the food guide pyramid (bread, cereal group) and concentrating on more fruits and vegetables along with carefully selected foods from the dairy and meat group. Any bread and cereal group choices should be whole grain and fiber-rich.

Either food fortification or supplementation in pill form should augment certain nutrient requirements, which may be impossible to obtain when a person is taking in fewer calories. Vitamins B12 and D and calcium are the common nutrients that potentially need to be supplemented. Also, fluid intake is vital-try for 8-10 servings of water (or equivalents) daily.

The following points will also help you maintain optimal nutritional care:

• Keep detailed records of the individual’s weight history, food preferences, aversions and food allergies, as well as a list of vitamins, minerals and other nutritional supplements.
  
• Distribute nutrient-dense food throughout the day at frequent intervals. Many people with dementia lose their ability to heed natural body cues of satiety or hunger.
  
• Encourage fluid intake in the form of nutrient-dense juices, soups, milkshakes, and smoothies. Because of age-related decreases in thirst cues, the risk for dehydration increases.
  
• Adjust the volumes and textures of food to provide variety and help maintain an interest in eating.
  
• Offer reminders to eat and drink as necessary to keep the person focused on eating.

Note: Difficulty in swallowing (dysphagia) is a common condition in those with Alzheimer’s disease or dementia. Have the cause of this condition evaluated by a healthcare provider, because there are different kinds or treatment, including changes in diet or medication.

Environment

It is important to create a comfortable environment with attention to a person’s surroundings, both physical and emotional. To do this:

• Minimize distractions in the dining area. Avoid bright, harsh lighting by using indirect, lower wattage lamps around the table.
• Provide comfortable furniture that allows the person to maintain an appropriate body position for self-feeding.
• Vary the colors of the dishes and/or placemats and offer a meal containing foods of different colors and textures. A colorful presentation may prompt a person to focus on eating. Try adding a piece of parsley if you lack time for anything else.
• Remain patient. Finally, problems of eating do not always stem from the person with dementia: An impatient caregiver can contribute to the unwillingness of a sick person to eat. A sense of being rushed often makes an ill person uneasy, which in turn decreases appetite. While it is not always easy, try to keep your patience and give yourself over to the task-as you gently encourage your loved one to eat-and eat well.