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DISCLAIMER ...
There is no hard and fast answer to addressing a problem behaviour.
The following information is provided as a tool to help the Caregiver find the solution that works for situation they are faced with.

Problem Behaviours - Eating

| Possible Causes | Coping Strategies | Other Considerations | Additional Information

In early stages of the disease, people with Alzheimer's may have difficulty preparing meals. They may forget they have food in the oven or cook something and forget to eat it. Food preparation problems may progress to difficulty eating, the ability to recognize thirst or hunger. The person may no longer know how to use a knife or fork and may lose interest in food altogether. Food may not smell or taste the same; it may become more difficult to chew and digest food.

Alzheimer's EatingSevere eating problems put the person with Alzheimer's at risk for weight loss, dehydration and malnutrition. Caregiver's should continue to ensure that the cared for person eats a well-balanced, nutrient-rich meals, even though a special diet may not be necessary. For example, the person with Alzheimer's needs to be under the continual supervision of a qualified medical doctor in order to stay in the best overall health possible.

Poor overall health is associated with greater symptoms of Alzheimer's, so maintaining healthy habits may reduce symptoms.

Possible Causes

Physiological or Medical Causes

  • Dry mouth
  • Parkinson's disease
  • Mouth discomfort from gum disease or ill-fitting dentures
  • Vision changes e.g. cannot see food or utensils properly
  • Chronic illness causing loss of appetite e.g. diabetes, stomach problems, heart disease, etc
  • Acute illness causing loss of appetite e.g. urinary infection, pneumonia, congestive heart failure.
  • Constipation
  • Depression causing a loss of appetite
  • Changing tastes due to medication or age
  • Muscle control in jaw or throat no longer functioning properly due to motor abilities declining in advanced dementia
  • Hunger sensations no longer understood or received by brain due to brain changes in dementia
  • Side effects of medication anti-depressants, mood elevators etc
  • Day and night sleep patterns reversed
  • Doesn't remember to stop and eat
  • Agitation

Environmental Causes

  • Relocation to new environment
  • Poor lighting ... unable to see food and utensils properly
  • Too many distractions ... such as noise, people, too much on the plate or table
  • Boredom ... may cause desire to eat all the time
  • Food is perceived as looking or smelling unappealing
  • Odors in environment ... dining room, kitchen, or hall can depress appetit

Other Causes

  • No longer understands how to eat
  • Can no longer coordinate use of silverware
  • Caregiver not giving simple or clear enough instructions.
  • Forgotten how to swallow
  • Task to complex
  • Feeling of being rushed by caregiver
  • Embarrassment at inability to do simple tasks ... use a fork or spoon
  • Fear or anxiety

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Coping Strategies

  • Have a good dental check-up of gums, teeth and dentures... Sometimes children's dentists (especially those who specialize in working with handicapped children) are good at working with agitated individuals.
    • Ask whether your dentist or hygienist will make house calls.
  • Have vision and glasses checked
  • Have a good medical work-up to discover any possible physical causes or medication problem contributing to appetite change.
  • Have an evaluation for depression done, if appetite loss becomes a problem.
  • Stroke shoulders and neck to relax person.
  • Try soft, relaxing music during meal.
  • Provide appetizing odors of fresh food cooking.
  • In nursing homes, reduce other odors, such as cleaning fluids or urine, in dining area.
  • Improve lighting in eating area, but avoid glares.
  • Reduce noise and distractions in dining area during meals:
  • In a large family, consider serving the person early and letting him/her join the family at supper for social reasons

In a nursing home, consider:

  • Small group dining ... Grouping according to eating abilities ... Allowing particularly agitated individuals to eat alone;
  • Reducing excessive noise, for example, by lowering ceiling or using textured wall hangings.
  • Reduce distractions at the table ... Avoid patterned placemats, plates, tablecloths.
    • Serve only one food at a time, if necessary.
    • Remove other distracting items from table.
  • Make eating simple ... Use bowls and cups that are larger than the portion of food.
    • Use bowls rather than plates.
    • Set place with only utensils that are needed.
  • Use bowls or plates that are different in color from the placemat to help the person more easily locate the plate.
  • Use brightly colored placemats.
  • Place a damp washcloth under the plate to keep it from sliding.
  • Don't use plastic utensils ... they are too light to manipulate easily and may break in the person's mouth.
  • Try bendable straws or cups with lids and spouts for liquids.
  • Use mugs for soups or stews.
  • Be sure to get mugs with big enough handles for easy holding.
  • Use assistive devices ... such as large handled silverware, plates with suction cups on bottom, plates with rims ... Or buy white plastic tubing, which can be cut and fit on utensils.
  • Serve "finger foods," such as french fries, cheese, small sandwiches, chicken or pork kebabs, fried chicken, fresh fruits or vegetables... Even very impaired people often manage finger foods well.
  • Try 'yawning' or asking the person to say "ah" if he/she won't open mouth.
  • Put a bite of food to lips as stimulus to open mouth.

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Coping Strategies (cont)

For chewing problems:

  • Try light pressure on lips or under chin to get started.
  • Give verbal instructions, i.e., "Chew now. And now swallow."
  • Demonstrate chewing.
  • Make sure person is in a comfortable position.
  • Avoid sticky foods such as bananas, peanut butter, white bread.
  • Avoid foods that fall apart or have tough skins, such as nuts.
  • Moisten foods with sauces, gravy, water... Bear in mind that some medications, such as antipsychotics, cause dryness of mouth.
  • Serve chopped soft foods.
  • Offer small bites, one at a time.

For swallowing problems:

  • Remind to swallow with each bite.
  • Stroke the throat gently
  • Check mouth periodically for food stored in cheek.
  • Omit foods that are hard to chew and swallow, such as popcorn, nuts, raw vegetables.
  • Offer small bites, one at a time.
  • Allow plenty of time between each bite.
  • Keep liquids at room temperature.
  • Moisten foods

For choking problems with liquids:

  • Try thicker liquids such as apricot juice, milk shakes, egg nogs.
  • Make cooked cereal with milk or water to help hydration.
  • Keep liquids at room temperature.
  • Notify your doctor of this problem

For choking problems with solid foods:

  • Try soft cooked foods,
  • such as scrambled eggs, canned fruit, cottage cheese, frozen yogurt, jello made with orange juice and fruits, chopped chicken, mashed potatoes, applesauce.
  • Notify your doctor of this problem

For sweet cravings:

  • Have medications checked.
  • Some antidepressant medications cause a craving for sweets.
  • Offer gum.
  • Try nutritious milk shakes or egg nogs

For overeating or insatiable hunger:

  • Try 5 or 6 small meals a day.
  • Have a tray of low calorie snacks available, such as apples, carrots, etc.
  • Consider whether activities, walks, or other exercise might distract the person.
  • Lock some foods in cupboards, if necessary, particularly if the person is overweight or on a special diet

For undereating:

  • Try a glass of juice, wine, or sherry ... if medications permit alcohol use before the meal to whet appetite.
  • Offer ice cream, milk shakes, or eggnogs.
  • Make sure the person is getting enough exercise to stimulate appetite.
  • Try to prepare familiar foods in familiar ways, especially foods that were favorites.
  • Consult doctor about the possibility of physical illness or depression.
  • Check with doctor about using supplement drinks, such as Carnation Instant Breakfast, Plus, Sustacel, Ensure.
  • If person is in nursing home, be sure he/she is actually receiving the supplements.
  • Check with doctor about using vitamin supplements.
  • Consult a doctor if there is significant weight loss
  • Try feeding all or most of one food before moving on to the next ... Some people become confused when the tastes and textures change rapidly.
  • Sit directly in front of the person if peripheral vision isn't good ... Show each spoonful to help orient.
  • Mix puddings or ice cream with other courses to sweeten, if this encourages person to eat.
  • Allow person to eat when hungry

General:

  • Make sure meals are offered at regular, consistent times everyday.
  • Try to make mealtimes simple, relaxed and calm.
  • Be sure to allow enough time for the meal ... Feeding a very impaired person can take 45 minutes or an hour.
  • Remind the person of the approaching meal ... if necessary, help him/her smell or taste a drop of the food before eating.
  • Be sure the person is in a comfortable, upright position for eating ... In later stages, it may be necessary to use a wheelchair, "Gerry" chair, or cardiac chair with special supports and/or restraints.
  • If necessary, coordinate tranquilizing medications with mealtimes to reduce agitation.
  • Verbally guide the person through the meal, if necessary, using simple, gentle, respectful language

When dining at a restaurant:

  • Choose quiet, well lit restaurants where service is fairly fast.
  • Consider carrying printed cards to hand waiters, which read, "My companion has Alzheimer's disease and cannot understand you. Please direct your questions to me.

In long term care settings:

  • Consider use of aprons instead of towels or hospital gowns.
  • Consider use of small, square tables to aid in socializing and to help establish boundaries.
  • Try making milk, coffee, or juice available first thing in the morning to take the edge off morning hunger.
  • Train staff, volunteers, or family members who assist with feeding to:
  • Allow enough time for each bite;
  • To use verbal cues and reminders;
  • To allow people to feed themselves whenever possible;
  • To gently wipe the mouth between bites;
  • To concentrate on the person being fed, and not talk or socialize with other staff.
  • Bring favorite foods, such as fruits, cookies, etc., to make eating a more pleasurable experience.
  • Encourage those staff who have been successful in feeding to consistently feed person whenever possible.

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Other Considerations

  • Observe carefully to begin to assess what might be causing eating or feeding problems.
    • Is the problem with ... Use of silverware?... Chewing?... Swallowing? ... Distraction? ... Noise? ... Too much food on plate? ... Caregiver impatience?
  • Keep in mind the person's past history with food... He/she may have always had a small appetite, been a voracious eater, or had a craving for sweets.
  • It is perfectly all right to miss an occasional meal.
  • Watch food temperatures... While warm food is more appetizing, some dementia patients have lost the ability to judge when food or drink is too hot.
    • Styrofoam cups not only hold the heat for a long time, but also tip over easily ... Some people try to eat the styrofoam.
  • Mouth care is extremely important with dementia victims... If it is impossible to get teeth brushed, try using toothettes or lemon-glycerine swabs, available at pharmacies.
  • Spoiled food in the refrigerator, hiding food, or not eating regularly may all be signs that someone living alone is in need of more supervision.
  • Many dementia victims do not get enough fluid, because they forget to drink or may no longer recognize the sensation of thirst.
    • Be sure to offer regular drinks of water, juice, or other fluids to avoid dehydration.
    • Symptoms of dehydration may include thirst, refusal to drink, flushing and fever, rapid pulse, dizziness, and confusion.
  • Many eating problems of dementia victims are temporary and will eventually pass as the person's abilities change.
  • Choking and swallowing problems can be extremely upsetting to family caregivers... It may be reassuring to discuss this with a physician or other health care professional.
    • The Heimlich maneuver, a first aid measure for choking, can be learned at the Red Cross.
  • Families MAY wish to discuss nursing home policies regarding the use of feeding syringes with people who eat slowly or refuse to eat.
  • Some dementia victims reach a point where they are unable to swallow or simply refuse to eat ... It is important for families to discuss feelings ahead of time about the use of feeding tubes.
  • To use or not use a feeding tube is a very personal, individual decision, but one that needs to be made in advance and discussed with medical and nursing home personnel.

Additional Information

Alzheimer's Association (ADRDA) chapter newsletters

Burnside, lrene. Nursing and the Aged (2nd Edition). New York: McGraw-Hill Book Company, 1981.

Glaser, Suzanne. How to Improve the First Stage of Digestion. Geriatric Nursing, Sept/Oct. 1981.

Gwyther, Lisa. Care of the Alzheimer's Patients: A Manual for Nursing Home Staff. American Health Care Association and the Alzheimer's Association (ADRDA), 1985.

Hiatt, Lorraine. Designing Therapeutic Dining. Nursing Homes, March/April 1981.

Mace, Nancy and Rabins, Peter. The 36-Hour Day. Baltimore: The Johns Hopkins University Press, 1981.

Powell, Leonore and Courtice, Katie. Alzheimer's Disease: A Guide for Families. Massachusetts: Addison-Wesley Publishing Company, 1983.

Safford, Florence. Caring for the Mentally Impaired Elderly: A Family Guide. New York: Henry Holt and Company, 1986.

Wheeler, Beverly. Eating Disorders in the Elderly. Ontario Association of Homes for the Aged Quarterly, April 1986.

Wolanin, Mary and Linda Phillips. Confusion: Prevention and Care. Missouri: The C. V. Mosby Company, 1981.

Tanner, Fredencka and Sharon Shaw. Caring: A Family Guide to Managing the Alzheimer's Patient at Home. New York: New York City Alzheimer's Resource Center, 1985.

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