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Putting sugar on potatoes and salt on puddings – exploring the difficulties of eating with dementia
Growing awareness of the rising problem of dementia has placed it on the government agenda. Indeed 2012 saw the launch of The Dementia Challenge by the Prime Minister, and the UK is to host the first G8 dementia summit in December to lead international action to tackle the condition.
Despite this attention, malnutrition in dementia patients remains a concern. The experience of Sheila Wainwright, who spoke movingly at the recent 8th Annual UK Dementia Congress of her husband’s dramatic weight loss from 13 to just 7 stone before he passed away, is still too common.
So what do we know about nutrition issues in people with dementia and is there any evidence that directs best practice?
The challenges of nutritional care in dementia
People with dementia can often experience problems relating to eating and drinking including poor appetite, communication problems, difficulties coordinating their movements to enable independent eating and even the ability to see foods on their plate. For frontline caregivers, nutritional challenges can be frustrating and perplexing; Refusing to eat, rejecting food, becoming too distracted to eat, not being able to stay seated long enough to eat a meal or use utensils properly, not recognizing food, and difficulty chewing are encountered when trying to encourage and improve consumption. For the person with dementia, though, inadequate food and fluid intake can mean much more—malnourishment, dehydration, and unintended weight loss that can negatively impact the person’s mood, behaviour, and physical functioning as dementia progresses, and lead to a downward spiral in overall health and quality of life.
Common problems with eating and drinking include
- Lack of recognition
- Changes in food preference (sweet tastes or stronger/spiced flavours)
- Texture / consistency becoming inappropriate
- Lack of motivation and concentration
- Decreased ability to recognise hunger / thirst and satiety
- Forgetting if eaten or how to eat
- Difficulties preparing food
- Poor manual or mental dexterity
- Inability to communicate likes and dislikes
- Cutlery becoming difficult to use or forgetting how it should be used
Initiatives to improve nutrition inpatients with dementia
A number of studies have assessed the impact of mealtime interventions on nutritional outcomes for the elderly living in residential care. These have included changes to food service, dining environment, staff training and feeding assistance.
There is moderate evidence that education and training programmes can increase intake and reduce feeding difficulties. Although inconsistent, the evidence is generally positive around the effect of mealtime practices and environment interventions on body weight and improved dietary intake. However more robust trials are needed to establish the full efficacy of such interventions, some of which are discussed below.
The Dining Environment
Modification to the mealtime environment and routine show some promising effects. In general a more informal family style eating environment with staff involvement and without distractions is associated with improvement in body weight and quality of life for those in nursing homes. Similar interventions in cognitively impaired residents have also suggested nutritional benefits.
Simple modifications to the dining environment have also been studied, for example, the use of high contrast coloured tableware. People with dementia can experience difficulty in differentiating shades of colour, such as not being able to see mashed potatoes on white plate. Studies have shown a significant increase in food and fluid intake when high contrast, plain, primary coloured tableware was used in comparison to low contrast or white tableware.
Brain changes in dementia can profoundly impact the ability to smell and taste. Because of this foods formerly disliked may no longer be unpleasant and foods once enjoyed may become unpalatable. Additionally, medication can be an unappreciated contributor to taste disorders and maintaining adequate oral hygiene can help maximise taste from food.
People with dementia may develop a preference for very sweet things or strong flavours. A preference for sweet foods can be incorporated into a balanced diet, for example by using naturally sweet vegetables or adding a little honey to vegetables like carrots and parsnips. Sauces such as apple or cranberry or chutneys can be added to sweeten dishes. Milk and fruit based puddings, like custard and stewed fruit or rice pudding, fruit and ice cream or tinned or fresh fruit can provide some useful nutrients.
Spices, herbs, onions, garlic, chilli, pepper, lemon juice, soy or Worcestershire sauce can be used to strengthen flavours, but the liberal use of additional salt should be avoided.
Use of Finger Foods
When cutlery becomes difficult to use or the person with dementia is always on the move or easily distracted, introducing a finger food menu can help. Foods that can be picked up with fingers are often easier to eat when coordination becomes difficult. This style of eating is less frustrating and may encourage a greater and calmer meal experience.
In marked contrast with assisted feeding, provision of finger foods can allow an individual to maintain control of when, what and how much is eaten. This can help preserve dignity, increase self-esteem and enable independence at a time where mobility and coordination are impaired.
The ability to eat and drink with dignity and independence is often taken for granted, yet it is key to quality of life, and often neglected in dementia. Nutritional care is only one piece of the critical puzzle of good dementia care, but an important one that can an impact on health and well-being. Within this, an approach that encompasses all facets of eating and drinking, from individual psychosocial factors to the dining experience, should be considered. Some small changes could make a real difference.