Unfortunately, persons with Alzheimer's disease (AD) and related dementias are at a very high risk for weight loss. Research shows that weight loss occurs frequently in the early stage of dementia and becomes more pronounced as the illness progresses.1 The medial temporal cortex, which is involved in feeding behavior and memory, is affected in the early stages of AD and continues to be a site of major AD pathology as the disease progresses. One study also showed that weight loss may be an early indicator of AD.2
The good news is that the caregiver and environment can have a positive impact on reducing weight loss associated with AD. As the creator of the Forget-Me-Not Care Model™ I had the good fortune to work as the Director of Well Being, one of the key positions within our organizational structure, for 1 year for Parc Provence, a skilled nursing facility for seniors with memory loss (www.ParcProvence.com).
During that time, our team worked very hard to implement progressive strategies to minimize weight loss and supplement use. Our efforts were successful with our weight loss at 1% of our census and our supplement use at 3% of our census, approximately 1 year after opening.
Below are some of the strategies that our team used to maximize intake, to reduce weight loss, and to minimize supplement use.
10 Tips to Minimize Weight Loss in Persons With AD and Related Dementia
Encourage exercise throughout the day to increase appetite. Keeping a person involved in daily exercise can enhance appetite. Consider options like music with movement, walking, dancing, and balloon volleyball for those in Allen Level 3 or 2. Consider these activities as well as swimming and exercise classes for those in Allen Level 4 or higher.
Over flavor food. Research has indicated that our taste buds decrease with normal aging and that our ability to taste may change further due to dementia. Therefore, consider adding a bit more spice to food to make food more flavorful.
Provide the greatest caloric load at the breakfast meal or in the case of a person who fluctuates, provide the highest caloric load at the meal in which the person is most alert. Research shows that people with dementia often eat best at breakfast. A small study that I conducted at one of my client sites (a skilled nursing facility) in 2005 confirmed that the highest intake for those living on the dementia unit occurred at the breakfast meal. A caveat to this suggestion is if the person tends to fluctuate in level of alertness or performance. In this case, consider making the meal in which the client has the greatest level of alertness and function as the meal with the greatest calorie load.
Incorporate food likes and avoid dislikes. This may sound obvious but it is a significant factor in appetite. The "one size fits all" philosophy does not work in this situation. Interview your client and/or the family to identify individual food preferences, then do your best to incorporate these into the person's individual plan or the group meal plan.
Maximize self-feeding skills. As the dementia disease progresses it becomes very important to actually observe the person while eating in order to identify approaches and/or adaptive devices that may foster the greatest level of self-feeding ability. Below are interventions that I often used for a person functioning in Allen Level 2 and/or 3. Remember that a person in level 2 can use finger foods and cups but not utensils.
use of plate guards
color contrast of the food with the plate and the plate with the table
present one item at a time with the proper utensil
if the person can not use a fork, try a spoon (level 3 only)
sit the person at a square table or use a place mat to help define "their space" to reduce picking off the other person's plate
use built up handles for utensils as grasp can become clumsy (level 3 only)
select glasses and cups in which you can easily see the liquid. Make sure the cup/glass selected is easy to grasp and hold for the specific client
make certain the person is sitting at the correct angles, is close to the table and feet are firmly planted on the floor or wheel chair leg peddles
Reduce over stimulation and distractions in the dining environment. Turn off the televisions, make sure that the staff keeps their voice down during the meals, and keep the table clear of clutter and unnecessary items. All of these things can be a distraction and will contribute to the start-and-stop behavior that we often see during meal time.
Always frequently monitor oral status. Oral issues can contribute to weight loss as it might be painful or difficult to chew and/or swallow. Make certain the person is receiving good oral care, any required dentures or partials fit properly and are in, and that any signs of pocketing or aspiration are immediately acted upon with a SLP referral.
Be sure food is tender and cut into small bites. Again, this might sound obvious but you would be amazed at how many times I see food presented that has not been cut to bite size pieces or a tough meat like cube steak chosen for a meal. We must do all that we can to ensure the person can chew and swallow the food safely. If not, the person might choke or simply put the fork down and stop eating.
Provide frequent meals and healthy but high calorie snacks throughout the day. We can make eating fun! Some ideas are to have a weekly dinner club, daily social/happy hour with ice cream, tea and cookies, cooking groups in which the clients eat and enjoy the fruits of their labor, and refreshments served throughout the day in between activities.
Make certain the food is presented within their visual field and the person is cued to initiate as required per their Allen level. Often I see food and drink items placed on a table and the caregiver leaves. A person in Allen Level 2 or 3 will likely not initiate. The caregiver must remember to place the items within 14-18 inches from eye level, or the client might not even know the food is there. Also, the caregiver must cue the client to initiate eating or drinking (verbal cues only for high Allen Level 3 and verbal cues with visual and/or tactile cues for low level 3 and level 2). For a person in level 3, they might be able to continue eating with infrequent cues and a person in level 2 will need assist provided 1:1 or in a very small group.
Also, if your client is living in the community alone, you will likely need to assist with meal planning and preparation as needed. In Allen Level 4 a person may be living alone even though he or she is not recommended to live alone until 4.6. Throughout level 4 the person often has difficulty with many aspects of acquiring the food in addition to being able to safely prepare the meal. Do not rely on verbal report in level 4. Often a person can tell you what meals that they are eating, talking in long-term memory, but when you open the refrigerator none of the items are present or they have spoiled.
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One of my aspirations is for all persons who engage in dementia care to ask "why" when a person demonstrates a new behavior or change in function. A reduction in eating and drinking would definitely be classified in this way. So, stop and ask yourself "why" this person might be eating less. Don't just accept this as a consequence of AD and related dementias. While it is true that AD pathology will impact nutrition and weight loss, there are many things that a skilled caregiver and therapist can do to stimulate appetite and self-feeding abilities. Our client's life may be dependant upon this as weight loss has been identified as a predictor of mortality.
White, H, et al. The association of weight change in Alzheimer's disease with severity of disease and mortality: A longitudinal analysis. J Am Geriatr Soc 1998; 46: 1223-1227.
Barrett-Connor, E, et al. Weight loss precedes dementia in community-dwelling older adults. J Am Geriatr Soc 1996; 44:1147-1152.