alzheimers.org.uk

Eating and drinking
People with dementia often experience various problems with eating and drinking. Eating a healthy, balanced diet is important. It can help maintain physical and mental wellbeing. This factsheet looks at the importance of a healthy diet and the difficulties a person with dementia may have with eating and drinking. It will also look at some practical ways to help a person with dementia eat and drink well.

The importance of eating and drinking
Eating and drinking well is important to stay healthy. A healthy and varied diet is likely to improve a person’s quality of life. Not eating enough can lead to weight loss and other problems including vulnerability to infection, reduced muscle strength and fatigue. People with dementia may become dehydrated if they are unable to communicate or recognise that they are thirsty, or if they forget to drink. This can lead to headaches, increased confusion, urinary tract infection and constipation. These can worsen the symptoms of dementia. While a healthy, balanced diet is important, in late-stage dementia the priority should be making sure the person with dementia takes on nutrition, and a higher-calorie diet may be appropriate. A dietitian can advise on what is best in a particular situation.

1

Weight loss Weight loss is common in people with dementia, although the causes vary. They may include lack of appetite, difficulties cooking, problems with communicating or recognising hunger, poor co-ordination, tiring more easily, and difficulties with chewing and swallowing. If the person is losing weight, the GP can refer them to a dietitian.

Common problems
Poor appetite, cognitive impairment, physical disabilities and sensory disabilities (hearing and sight loss) can cause the person with dementia to have problems eating and drinking. Although eating and drinking difficulties are fairly common in people with dementia, when a problem occurs it will be unique to the individual and their situation. When looking for a solution, the person’s beliefs, culture and life history should be considered. Any solutions should be tailored to meet the person’s needs. As dementia progresses, the person is likely to need more support to meet their needs. Poor appetite There are many reasons why a person may turn down food and drink. • Depression – Loss of appetite can be a sign of depression. Depression is common in people with dementia. There are effective treatments for depression, including medication and other therapies. If you suspect that this is the problem, consult your GP. For more information see factsheet 444, Depression and anxiety. • Communication – The person with dementia may have problems communicating that they are hungry or that they dislike the food they have been given. They may communicate their needs through their behaviour. For example, they may refuse to eat or hold food in their mouth. Giving people a choice of food, using 2

prompts and pictures, may help. For more information see factsheet 500, Communicating. • Pain – The person with dementia may be in pain, causing eating to be uncomfortable. They may have problems with their dentures, sore gums or painful teeth. Oral hygiene and regular mouth checks are important. For more information see factsheet 448, Dental care and dementia. • Tiredness – This can also be a cause of people with dementia not eating or giving up part way through a meal. It can also lead to other difficulties such as problems with concentration or difficulties with coordination. It’s important to be aware of this and support the person to eat when they are most alert. Eating small portions more regularly is better than having set mealtimes. • Medication – Changes to medication or dosage can result in appetite changes. If you think this may be the case, speak to the GP. • Physical activity – If the person is not very active during the day, they may not feel hungry. Encouraging them to be active will be good for their wellbeing and may increase the person’s appetite. Equally, if the person is very active or restless (walking about or fidgeting) they may use extra calories and need to eat more to replace them. For more information see factsheet 529, Exercise and physical activity for people with dementia. • Constipation – This is a common problem and can result in the person feeling bloated or nauseous, making them less likely to want to eat. Try to prevent constipation by encouraging activity, offering fibre-rich foods and providing plenty of fluids. If constipation becomes a problem, speak to the GP. Encouraging appetite: tips for carers There are lots of ways to stimulate appetite and interest in food and drink. Knowing the person will help, as everyone has their own routines, preferences and needs. You will also have a better idea about their likes and dislikes. It’s also important to think about what they can physically manage. 3

• Regular snacks or small meals are better than set mealtimes. • Make food look and smell appealing. Use different tastes, colours and smells. The aroma of cooking can stimulate someone’s appetite. • Look for opportunities to encourage the person to eat. If the person with dementia is awake for much of the night then night-time snacks may be a good idea. • Provide food the person likes. Try not to overload the plate with too much food; small and regular portions often work best. • Try different types of food, eg milkshakes or smoothies. • Food tastes may change, so experiment with stronger flavours or sweet foods. • Do not withhold desserts if the person hasn’t eaten their savoury meal. They may prefer the taste of the dessert. • If food goes cold it will lose its appeal. It can help to serve half portions to keep food warm, or to use the microwave to reheat food. • If the person is having difficulties chewing or swallowing, try naturally soft food such as scrambled egg or stewed apple in the first instance, before considering pureed food. • If you do consider pureed food, seek advice from a dietitian or speech and language therapist to make sure it’s nutritious and remains flavoursome. • Encourage the person to get involved at mealtimes. They could help prepare the food or lay the table. • Positive encouragement and gentle reminders to eat, and of what the food is, may help. • A relaxed, friendly atmosphere with some soft music may help. • Use eating and drinking as an opportunity for activity and social stimulation. • It is always best to aim for the least stressful solutions. Common sense and a creative approach often help.

4

Cognitive difficulties
Recognising food and drink People with dementia may struggle to recognise food and drink, which can result in it going uneaten. This can be due to damage that dementia causes to the brain, unfamiliar food, or how food is presented. If the person with dementia has problems with their sight, they may not be able to see the food. It may help to explain what the food is and to use pictures. Make sure the person is wearing the correct glasses. It’s important not to assume that the person doesn’t want to eat. Concentration People with dementia may not be able to concentrate well, which means they may have difficulties focusing on a meal until it is finished. This may be because they are tired. Don’t assume someone has finished because they have stopped eating. Finger foods and smaller portions can help to make the task easier. If you are helping someone to eat and it goes on for too long, it can turn into a negative experience. The food can become cold or the process may be overwhelming.

Motor difficulties
Problems with coordination People with dementia may struggle to handle cutlery or pick up a glass. They may also have trouble getting food from the plate to their mouth. A person with dementia may not open their mouth as food approaches and may need reminding to do so. They may also have other conditions that affect their coordination, for example Parkinson’s disease. This could lead them to avoid mealtimes because they are embarrassed by their difficulties or want to avoid struggling. • If the person is struggling with a knife and fork, chop up food so it can be eaten with a spoon. 5

• If the person appears to have difficulty using cutlery, you may need to prompt the person and guide their hand to their mouth to remind them of the process involved. • Try finger foods such as sandwiches, slices of fruit, vegetables, sausages, cheese and quiche. These are often easier to eat when coordination becomes difficult. • Let the person eat where they feel comfortable. • Speak to an occupational therapist about aids that can help, such as specially adapted cutlery or non-spill cups. Chewing and swallowing A person with dementia may have difficulties with chewing food. They may forget to chew or they may hold food in their mouth. Certain foods, such as sweetcorn or dry biscuits, may be more difficult for the person to chew or swallow. These should be avoided. Good oral hygiene is important. If the person is experiencing pain in their mouth it will make chewing uncomfortable and difficult. If the person wears dentures, they should be comfortable and fitted properly. People with dementia can tire easily. Eating soft, moist food that needs minimal chewing can help. As dementia progresses, swallowing difficulties (called dysphagia) become more common, although they can vary from person to person. If a person is having difficulty with swallowing, a referral to a speech and language therapist can help. Difficulties can include holding food in the mouth, continuous chewing, and leaving harder-to-chew foods (eg hard vegetables) on the plate. Weight loss, malnutrition and dehydration can also be consequences of swallowing difficulties. If the person is drowsy or lying down, they may struggle to swallow safely. Ensure that they are alert, comfortable and sitting upright or, if in bed, well positioned, before offering food and drink. A physiotherapist can advise on positioning techniques and an 6

occupational therapist can advise on aids for eating and drinking. Ask the GP for a referral.

Sensory difficulties
Temperature Some people with dementia will lose the ability to judge the temperature of food. Make sure food is not too hot, as it could burn the person’s mouth and result in eating becoming uncomfortable. Drinking enough The sensation of thirst changes as people get older, which can sometimes mean the person isn’t aware they’re thirsty. A person with dementia may also have similar problems. They may be less able to provide drinks for themselves. The person should be encouraged to drink throughout the day. It’s recommended that the person drinks at least 1.2 litres a day. Just placing a drink in front of someone doesn’t mean they will drink it. Also, an empty cup doesn’t always mean that the person has drunk its contents. It may have been spilled, drunk by someone else, or poured away. Ensuring the person drinks enough: tips for carers • Have a drink on hand whenever the person is eating something. • Use a clear glass so the person can see what’s inside, or a brightly coloured cup to draw attention. • If possible, offer the person the cup or put it in their line of sight. • Describe what the drink is and where it is, so that if the person has a problem with their sight they are still able to find the drink. • Offer different types of drink (both hot and cold) throughout the day. • Make sure the cup or glass is suitable – not too heavy or a difficult shape. • Foods that are high in fluid can help, eg gravy, jelly and ice cream. 7

Behavioural difficulties
Eating behaviours A person with dementia may refuse to eat food or may spit it out. This may be because they dislike the food, are trying to communicate something such as the food being too hot, or they are unsure what to do with the food. The person with dementia may become angry or agitated or exhibit challenging behaviour during mealtimes. This can be for a variety of reasons, such as frustration at any difficulties they are having, feeling rushed, the environment they are in, the people that they are with, or not liking the food. They may not want to accept assistance with eating. It can be a challenge to identify what the problem is, particularly if the person is struggling to find the words to explain it. It is important to remember that these reactions are not a deliberate attempt to be ‘difficult’, or a personal attack. Try not to rush the person with dementia, and help them maintain as much independence as possible. Look for non-verbal clues such as body language and eye contact as a means of communication. If a person is agitated or distressed, do not put pressure on them to eat or drink. Wait until the person is calm and less anxious before offering food and drink. Changes in eating habits and food preference People with dementia can experience changes in eating habits, both in terms of how much food they eat and when, and what food they prefer. As a person gets older it is common for the senses of taste and smell to decline, which can lead to food being less palatable. People may have a preference for additional sugar and salt. It is not uncommon for people with dementia to develop a fondness for sweet foods. People with dementia may enjoy unusual flavour combinations or ways of eating. Often people mix sweet and savoury food and flavours. People may start to have a less varied diet, only eating certain types of food. 8

Damage to specific parts of the brain or a change in taste perception may mean some people start to enjoy tastes they never liked before or dislike foods they always liked, so those providing food should try to be flexible. People with Alzheimer’s disease can show even greater problems with their sense of smell, especially with odour memory. Catering for changing eating habits: tips for carers • If someone has a preference for sweet foods, fruit may be a healthier option. • Add small amounts of sugar or honey to savoury food. • Sweet sauces or chutneys can be served with savoury dinners. • Herbs and spices could be used to enhance flavours. • Try food the person has never eaten before. As dementia progresses, a person may put non-food items into their mouths, eg napkins or soap. There could be a number of reasons for this, including: • The person no longer recognises the item for what it is or understands what it is for. Remove from view the items that the person may confuse for food. • The person may be hungry. Offer food as an alternative to the item. Ensure that food is available, easy to see (both within eyesight and in clear contrast with the plate or immediate environment) and easy to access throughout the day so the person can eat when they want to. Overeating Some people with dementia may overeat. Reasons for this include forgetting they have recently eaten or being concerned about where the next meal is coming from. Overeating may also be associated with eating inappropriate foods or non-food items, as well as frequently asking or searching for food. This can be a stressful situation for everyone involved. 9

People with behavioural variant frontotemporal dementia are likely to experience excessive eating and other changes to eating behaviour, such as changes in dietary preference and obsession with particular foods. For more information see factsheet 404, What is frontotemporal dementia? Tackling overeating: tips for carers • Ensure that the person has something to do so they do not feel bored or lonely. • Leave bite-sized fruit, for example chopped bananas, orange segments or grapes, within reach of the person to snack on as desired. • Some carers remove certain foods from the house and try to manage how much a person eats. • If the person eats non-food items then it may help to remove these and offer snacks as a distraction. • If the person has developed a preference for particular foods, to the extent that this dramatically restricts the variety of food they are eating, or they are struggling with excess weight gain, ask the GP for a referral to a dietitian.

Eating environment
The environment plays an important part in the eating and drinking experience. It can affect how much a person enjoys eating and the amount they eat. A good mealtime experience can have a positive impact on the person’s health and wellbeing. Improving the eating environment: tips for carers • Eat with the person. This will help make eating a social activity and can also help maintain independence as they may be able to copy you. • Make the environment as stimulating to the senses as possible: familiar sounds of cooking, smells of the kitchen and food, and familiar sights such as tablecloths with flowers can all help. 10

• Some people enjoy eating with company; others prefer to eat on their own. Sometimes this will vary from one meal to another. Either way, make sure the person has enough space. • A noisy environment can be distracting. The eating environment should be calm and relaxing. Switch off background noise. • Let the person with dementia choose where they sit and eat. They should also be able to choose what they want to eat, within reason. • Some people with dementia will also have problems with their sight. They may not be able to see the food in front of them. Make sure the food is colourful and the environment is well lit. It may also help to give a verbal description of the food. • Use colour to support the person – the colours of the food, plate and table should be different. Avoiding patterned plates is important. • Try not to worry about mess; it’s more important for the person to eat than to be tidy.

Meal preparation
It is important to keep people involved in preparing food and drink. This is because it can help to maintain certain skills, and keep the person interested in food and drink. You could break down preparation into individual tasks, for example preparing the vegetables or buttering bread. It’s important for the person with dementia to do as much as they can for themselves. If the person has carers coming in, they may be able to help with the shopping or preparing the food. Online ordering and delivery may be a good way to ensure that there is fresh food in the house.

Living alone
Meals on wheels may be an option for people who need support to prepare food. However, the service is not available everywhere. Contact your local council or Alzheimer’s Society office to see what’s available in your area. Frozen or refrigerated ready meals could be another option. Spoiled food, hidden food or not eating regularly are 11

signs that the person with dementia may need extra support. It is possible to arrange for home carers to visit the person at mealtimes and either prepare a meal for them, or stay with them while they eat. Contact your local social services department for more information. Although a person with dementia may experience difficulties with eating and drinking, it’s important to remember there are things that can support them. Offering solutions, making adaptations and increasing your knowledge about difficulties will mean that you can support the person with dementia to eat and drink well.

Useful organisations
British Dietetic Association 5th Floor, Charles House 148/9 Great Charles Street Queensway Birmingham B3 3HT T 0121 200 8080 E info@bda.uk.com W www.bda.uk.com The British Dietetic Association is the professional association and trade union for dietitians. Freelance Dietitians W www.freelancedietitians.org The Freelance Dietitians site is a database of experienced registered dietitians who either provide expert dietary guidance to individuals privately or offer a wide range of nutrition services to organisations such as food companies, schools, care homes, workplaces and health departments. Freelance Dietitians is a specialist group of The British Dietetic Association. 12

This publication contains information and general advice. It should not be used as a substitute for personalised advice from a qualified professional. Alzheimer’s Society does not accept any liability arising from its use. We strive to ensure that the content is accurate and up to date, but information can change over time. Please refer to our website for the latest version and for full terms and conditions. © Alzheimer’s Society, 2013. All rights reserved. Except for personal use, no part of this work may be distributed, reproduced, downloaded, transmitted or stored in any form without the written permission of Alzheimer’s Society.

Factsheet 511LP Last reviewed: October 2013 Next review due: October 2015 Reviewed by: Dr Karen Dodd, Associate Director for Therapies for People with Learning Disabilities and Older People’s Mental Health Services / Consultant Clinical Psychologist, Surrey and Borders Partnership NHS Foundation Trust; Alison Smith, Registered Dietitian, Spokesperson for Nutrition Advisory Group for Older People (NAGE), a Specialist Group of the British Dietetic Association (BDA) This factsheet has also been reviewed by people affected by dementia. A list of sources is available on request.

Alzheimer’s Society National Dementia Helpline England, Wales and Northern Ireland: 0300 222 11 22 9am–5pm Monday–Friday 10am–4pm Saturday–Sunday alzheimers.org.uk Alzheimer’s Society is the UK’s leading support and research charity for people with dementia, their families and carers.

Registered charity no. 296645. A company limited by guarantee and registered in England no. 2115499

13