Make the Meals Count: Nourishing a Loved One with Alzheimer’s Disease
June marks the observance of National Alzheimer’s and Brain Awareness Month, sponsored by the Alzheimer’s Association. As our population ages, more individuals will be directly impacted by Alzheimer’s Disease. Currently, approximately 6 million individuals live with Alzheimer’s in the US, and experts believe this number will reach 13 million within the next thirty years.1 While research suggests that diet plays a key role in overall brain health and the potential development of Alzheimer’s and other dementias, the importance of quality nutrition extends throughout the affected individual’s life. However, cognitive decline can make mealtimes challenging for those with Alzheimer’s and their caretakers.2
There is a multitude of challenges for those impacted by neurological conditions such as dementia or Alzheimer’s, many of which relate to activities of daily living (ADLs) and independence. Many impacted by the disease experience confusion, agitation, anxiety, decreased ability to chew or swallow, taste and smell changes, and decreased awareness of hunger and satiety cues – all creating unique hurdles regarding adequate nutrition.2 As the disease progresses, it can be extremely difficult to watch your loved one struggle to care for themselves and accept care from others. It is important to remember that these challenges are shared amongst many with the disease and that you are not alone (to find support and other resources, visit the Alzheimer’s Foundation of America’s website linked here).
Nourishing your loved one with Alzheimer’s can often feel like a game of chance. On good days, your loved one may be engaged and interested in food, while on more difficult days, this isn’t the case. Sometimes, engagement and interest can shift during the meal. While every individual’s bout with Alzheimer’s is unique to them, some patterns and similarities are common among those who suffer from the disease. Below are common nutrition-related concerns in this population and strategies that you may find helpful to combat these mealtime challenges.
Most older adults are at risk of dehydration, causing complications like urinary tract infections, acute kidney injuries, or poor cognition.3 Those with Alzheimer’s may not recognize thirst or forget when they last had something to drink. To improve fluid intake, consider the following strategies:
- Offer 4-6 oz of water when providing oral medications.
- Provide visual cues to drink throughout the day, such as a refillable water bottle kept near your loved one while they rest or participate in activities.
- Offer water-rich foods such as watermelon, cucumbers, broths, strawberries, melon, and oranges, as tolerated.4
- Encourage your loved one to drink throughout the day and model adequate hydration by taking sips together.
- Some older adults with Alzheimer’s develop a fear or discomfort around water.5 Consider darker-colored drinkware as an option if this is something your loved one struggles with.5
- Adding colorful fruits and herbs may make water more interesting and visually appealing. Lemon, orange, or lime slices, strawberries, cucumbers, and mint leaves may be fun additions to try with your loved one. Be mindful that these fun additions can pose a choking risk and should not be poured directly into your loved one’s cup. Instead, choose a clear pitcher to display these visually appealing and tasty options (such as this one from Amazon).
Many adults experience decreased appetite with age. This may be caused by a multitude of factors – decreased sense of smell or taste, less physical activity requiring less energy to fuel, and loss of lean body mass (metabolically active tissue that requires caloric energy to maintain), just to name a few.6
Those with Alzheimer’s have additional challenges that make it difficult to eat enough food throughout the day. Forgetfulness may result in missed meals and snacks, should the individual still maintain some level of independence during the day. Some experience agitation due to a lack of familiarity with surroundings or those present for the meal, influencing their ability or willingness to engage with the food. Others may be unable to tap into their hunger cues or communicate these to their caretakers. Additionally, older adults may not recognize foods or see them clearly, thus creating another barrier to intake. Malnutrition is common in those with Alzheimer’s and may result in further cognitive and physical decline, placing key importance on maintaining or improving nutritional status.7
It can be challenging to feel as though your loved one isn’t eating enough during the day, especially when they have no interest in food. To improve intake and engagement at mealtimes, consider the following strategies:
- Offer foods on plain, pattern-free dishes. Bright white plates and bowls make the foods “pop” and create a visually pleasing effect, while colorful designs can be distracting or confusing.8
- Consider a simple place setting and try offering only one utensil. Those with Alzheimer’s may become overwhelmed with too many options but may be more confident and willing to take bites if offered one choice of utensil, such as a spoon.8
- Allow your loved one to be near the kitchen during food preparation. Digestion begins when we see and smell tasty food – before we even take our first bite! Your loved one may be more interested in a meal if they have been exposed to all the delicious smells swirling around the kitchen or living space during preparation.
- Make every bite count with nutrient and energy-dense foods should your loved one struggle to maintain or gain weight (if underweight). Additional calories can be offered by mixing nut butter into oatmeal, providing small snacks throughout the day, encouraging small sips of oral nutrition supplements, and serving vegetables with a drizzle of heart-healthy olive or avocado oil.
- Include preferred foods at meals and practice flexibility with foods served at home.8 Some individuals may develop strong preferences for specific food items. These can be incorporated and served alongside other options to offer a varied diet. On the other hand, an individual may suddenly reject foods they previously enjoyed. Make the most of their preferred foods and practice flexibility regarding when they are offered. For example, an individual with Alzheimer’s may enjoy chicken noodle soup and ask for this at breakfast. While this isn’t a typical “breakfast food,” allowing them to have the soup could improve their intake, while insisting on cereal or toast with eggs may cause frustration or result in poor intake. It is okay to be a little unconventional!
- Try offering one food at a time to prevent overwhelm and increase focus on the task at hand.
- Gentle cues such as a light tap on the hand, short verbal instructions, guiding their hand and utensil to their mouth, and offering encouragement to take another bite can be helpful if your loved one appears disinterested in eating.8
- Orient your loved one to their plate when serving should they become unfamiliar with what is being offered. Simply saying, “this is _____,” may provide context to your loved one and invite them to take a bite.
- Make meals social by discussing happy topics, eating together, maintaining eye contact, and playing quiet, soothing music.8 Try to limit noisy distractions such as a loud television in a nearby room.
- Some may find it more comfortable to sit beside their caregiver rather than across the table; play with where you sit during meals to see if this impacts your loved ones’ attitude and attention at mealtime.
As cogitation declines, adults with Alzheimer’s are at an increased risk of accidental injury. Unfortunately, the kitchen creates an opportunity for accidents, including burns, cuts, slips, and poor food safety.9 For more information regarding home safety modifications, visit the Alzheimer’s Association website.
- Stove knob covers may be helpful to prevent your loved one from turning on burners.9
- Avoid using decorative faux food items such as fruits or vegetables to prevent confusion and accidental ingestion.9
- Sugar substitutes, seasonings and spices, medications, and supplements should be kept out of sight and monitored to prevent accidental ingestion.9
- Engaging in pleasurable activities is an important factor in maintaining the quality of life and can be helpful in promoting judgment and processing skills. Additionally, those with Alzheimer’s may express a desire for independence and may be interested in assisting with kitchen tasks and food preparation. Invite your loved one to help as appropriate and provide clear, concise instructions. For example, they can help you mix a batter, set the table with napkins and placemats, place rolls on a pan to be heated, shuck corn, pick herbs, spread nut butter on bread with a spoon, and pour measured ingredients into a bowl.
- Check the temperature of foods before serving to prevent accidental burns.8
Loss of coordination is a common concern for those with Alzheimer’s and complicates the use of utensils such as forks, spoons, and knives.10 Some individuals may willingly accept assistance with feeding, while others may prefer more independence. Adaptive feeding equipment specifically made for those with Alzheimer’s may be helpful and is available through an occupational therapist or online vendors such as the Elder Store. Consider speaking with an occupational therapist should you desire more information on what tools may be best for your loved one and their abilities.
- Cups with wide rims and handles may be easier to drink from than smaller options that are more difficult to grip and coordinate. Cups with a lid may be helpful to reduce spills and any embarrassment this may cause your loved one.11
- Finger foods such as sandwiches, chicken nuggets, blueberries, and steamed vegetables that do not require a utensil may allow your loved one to feed themself independently.11
- Place food items within easy reach at mealtimes.
- Liquids such as soups or broths are easier to spill and may require more assistance should your loved one struggle grasping a spoon. Strained soups or clear broths may be easier to drink out of a mug; however, this should be done with caution to ensure that chunks of food do not present as a choking hazard and only drinkable, consistent liquids are offered.
Poor Dentition / Oral Hygiene
Poor oral hygiene can result in increased bacteria and is a leading cause of aspiration pneumonia in those with swallowing difficulties.11 Additionally, many older adults do not wear properly fitted or secured dentures due to weight loss or loss of gum tissue.11 Mouth sores, dry mouth, bleeding or decaying gums, and other markers of poor dentition can be painful for the individual and make eating less desirable.12
It is best to discuss dental hygiene with a specialized practitioner, primary care provider, or dentist to understand the root cause of an issue. Some families and loved ones may find the following helpful to improve intake in cases of poor dentition:
- If mouth sores are present, colder foods may be more tolerated. Acidic foods such as tomatoes and tomato products, vinegar-based marinades and dressings, citrus and citrus juices, and high-salt foods may be more irritating and should be avoided.
- Offer softer foods for those with ill-fitting or missing dentures.12 Mashed potatoes, yogurt, smoothies, applesauce, and scrambled eggs are all examples of foods that can be consumed in cases of missing teeth.
- Offer small sips of water throughout the day to ensure hydration and reduce dry mouth. Discuss symptoms of dry mouth with your loved one’s primary care physician to determine probable causes, such as medication side effects.
- Alternate bites of food with sips of liquid to moisten the pallet and assist in chewing.11
- Sauces and gravies can be helpful to make foods easier to chew in cases of missing teeth or dry mouth.
Many of us rarely consider that swallowing requires a significant amount of muscle coordination. Individuals with Alzheimer’s Disease often lose this coordination as the disease progresses, increasing the risk of aspiration and subsequent complications such as pneumonia.11 Specialized tests, such as a swallow study completed by a speech-language pathologist, may be recommended for those with persistent swallowing difficulties or choking episodes. Speak with your loved one’s primary care provider for more information on swallowing evaluations.
There are several mealtime modifications that may be helpful for those with some difficulty swallowing or to reduce the risk of choking:
- Encourage your loved one to sit upright during the meal to reduce aspiration risk. If your loved one struggles to stay upright, consider positioning them in a chair with armrests to assist their posture. If able, it is recommended to have your loved one sit upright for 30 minutes after the meal to further reduce aspiration risk.11
- Encourage slow bites as able and avoid rushing your loved one during the meal.11,12 Ideally, your loved one should swallow before taking another bite to ensure a clear oral cavity. Gentle cues such as “please swallow the food in your mouth first” may be helpful to guide this process.
- It may be helpful to cut food into bite-sized pieces to reduce the risk of your loved one taking too large of a bite.12 This can be done before placing the food in front of your loved one.
- Consider providing meals and snacks when your loved one is most alert.11 Falling asleep during mealtimes can result in choking. Often, this may mean serving a larger meal earlier in the day rather than at dinnertime.
- Straws, while seemingly helpful, can be dangerous should they be placed too far back in the oral cavity.12 Additionally, they require coordination to move the liquid through the straw and into the mouth and are generally not recommended for those with swallowing concerns (while some may be able to use them just fine!).
As we age, our bodies naturally begin to lose lean muscle mass. This loss may be greatest, however, in those who are not physically active, declining somewhere between 3-5% each decade beginning around age 30.13,14 Many caretakers express that their loved ones become more sedentary as the disease progresses. Not only does decreased activity result in loss of lean mass, but this can also result in loss of functional movement such as walking, navigating around the home, standing, and balance.15,16 Caregivers should encourage their loved ones to engage in short bouts of movement as tolerated. Additionally, movement can increase appetite and therefore may result in improved dietary intake. Other benefits of exercise for those with Alzheimer’s may include the preservation of reasoning and judgment skills.17
- While most experts recommend exercising up to 30 to 60 minutes several times throughout the week, it is important to remember that this may not be feasible for those with late-stage Alzheimer’s disease.
- Any movement, no matter how long, should be encouraged. This may look like a walk to the end of the driveway to collect the mail, allowing your loved one to assist in small chores such as folding towels or putting away groceries, dancing in the living room to their favorite songs, or even more structured activities such as going to the putting green or an at-home chair yoga class via YouTube (such as the video linked here). No matter how small, movement is important and may improve the quality of life for those with the disease.
Lastly, we want to recognize that caring for a loved one with Alzheimer’s can often feel isolating, emotionally challenging, and physically draining. Try to remember that you are not alone on this journey and that there are many others also working to best support their loved ones. Some of the tips outlined above may resonate with you and be helpful, while others may fall flat – navigating mealtimes can require a lot of trial and error! Additional support and resources can be found through the National Institute on Aging, linked here.
- Alzheimer’s disease facts and figures. Alzheimer’s Disease and Dementia. https://www.alz.org/alzheimers-dementia/facts-figures. Accessed June 27, 2022.
- Escott-Stump S. Nutrition & Diagnosis Related Care. Wolters Kluwer; 2022.
- Dehydration. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/dehydration/symptoms-causes/syc-20354086. Published October 14, 2021. Accessed June 27, 2022.
- Elliott B. 19 water-rich foods that help you stay hydrated. Healthline. https://www.healthline.com/nutrition/19-hydrating-foods#TOC_TITLE_HDR_9. Published August 9, 2017. Accessed June 27, 2022.
- 5 ways to prevent dehydration when a senior has alzheimer’s. Five Star Senior Living. https://www.fivestarseniorliving.com/blog/5-ways-to-prevent-dehydration-when-a-senior-has-alzheimers#:~:text=Enhance%20water%3A%20You%20can%20also,of%20a%20glass%20of%20water. Published June 28, 2019. Accessed June 27, 2022.
- Pilgrim AL, Robinson SM, Sayer AA, Roberts HC. An overview of appetite decline in older people. Nurs Older People. 2015;27(5):29-35. doi:10.7748/nop.27.5.29.e697
- Kimura A, Sugimoto T, Kitamori K, Saji N, Niida S, Toba K, Sakurai T. Malnutrition is Associated with Behavioral and Psychiatric Symptoms of Dementia in Older Women with Mild Cognitive Impairment and Early-Stage Alzheimer’s Disease. Nutrients. 2019; 11(8):1951. https://doi.org/10.3390/nu11081951
- Food and eating. Alzheimer’s Disease and Dementia. https://www.alz.org/help-support/caregiving/daily-care/food-eating?gclid=CjwKCAjwquWVBhBrEiwAt1Kmwhv2D8-uC6Fasgjew931_bi0sS0w_vWR5yzTSrKlfUzmIUVPdX49nRoC1WsQAvD_BwE. Accessed June 27, 2022.
- Home safety. Alzheimer’s Disease and Dementia. https://www.alz.org/help-support/caregiving/safety/home-safety#:~:text=Avoid%20safety%20hazards%20in%20the,Disconnect%20the%20garbage%20disposal. Accessed June 27, 2022.
- How physical and sensory difficulties can affect eating. Alzheimer’s Society. https://www.alzheimers.org.uk/get-support/daily-living/eating-physical-sensory-difficulties. Published June 1, 2022. Accessed June 27, 2022.
- Desai RV. Caregiver’s guide to dysphagia in dementia. National Foundation of Swallowing Disorders. https://swallowingdisorderfoundation.com/caregivers-guide-dysphagia-dementia/. Published June 7, 2017. Accessed June 27, 2022.
- Caring for a person with late-stage alzheimer’s disease. National Institute on Aging. https://www.nia.nih.gov/health/caring-late-stage-alzheimers-disease#eats. Accessed June 27, 2022.
- Preserve your muscle mass. Harvard Health. https://www.health.harvard.edu/staying-healthy/preserve-your-muscle-mass#:~:text=Age%2Drelated%20muscle%20loss%2C%20called,muscle%20mass%20during%20their%20lifetimes. Published February 19, 2016. Accessed June 27, 2022.
- Volpi E, Nazemi R, Fujita S. Muscle tissue changes with aging. Curr Opin Clin Nutr Metab Care. 2004;7(4):405-410. doi:10.1097/01.mco.0000134362.76653.b2
- Gronek P, Balko S, Gronek J, et al. Physical Activity and Alzheimer’s Disease: A Narrative Review. Aging Dis. 2019;10(6):1282-1292. Published 2019 Dec 1. doi:10.14336/AD.2019.0226
- Chen K-H, Chen H-H, Li L, Lin H-chen, Chen C-L, Chen N-C. The impact of exercise on patients with dementia. Medicine. 2020;99(23). doi:10.1097/md.0000000000020597
- Alzheimer’s disease: Can exercise prevent memory loss? Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/expert-answers/alzheimers-disease/faq-20057881#:~:text=Exercising%20several%20times%20a%20week,disease%20or%20mild%20cognitive%20impairment. Published May 12, 2021. Accessed June 27, 2022.