1. Doesn't eat, won't eat
The person may forget mealtimes altogether because of memory loss.
The person may not eat much during meals because of:
- A short attention span.
- Confusion about how to use utensils.
- Confusion about how to eat the particular food served.
- Something problematic about the food (temperature, flavor, lack of familiarity).
- A physical impairment (sore mouth, upset stomach, reaction to a new medication, problem with denture fit).
What to do
- First be sure you're dealing with a true lack of sufficient calories and nutrition, not merely a finicky eater or a small appetite. Older sedentary people generally need fewer calories than those who are younger and more active. So avoid comparing an older adult to other members of the household.
- Rule out physical problems by checking in with a doctor, especially if the change seems sudden or the person is losing weight.
- Avoid coaxing and cajoling, which can set up a power struggle. Better to focus on more subtle strategies.
- Serve meals and snacks at consistent times to build a routine that's expected.
- Allow plenty of time for meals so the person doesn't feel rushed. If kids are present, don't make them fidget and wait until everyone has finished each course (which can make the person with dementia feel rushed or push her to say prematurely that she's finished). Serve the person with dementia at her own pace.
- Help the person focus on the meal at hand: Turn off background noise. Remove clutter from the table (papers, books, napkin holders).
- Another way to help focus is to highlight the plate and cup by putting them on a contrasting solid placemat (for example, white plate on red placemat). A study in Clinical Nutrition found that people with Alzheimer's eat and drink more when using high-contrast tableware.
- Avoid patterned dishes or table coverings, which can be distracting.
- Offer matter-of-fact, gentle prompts during the meal (in later stages of the disease): "Pick up the fork . . . scoop up the potatoes . . . take a bite."
- Focus more on protein than perfect nutritional balance; serve foods with protein and calcium at each meal.
- Tilt toward high-caloric, nutrition-dense foods for a birdlike eater, such as dishes made with cheese, butter, nut butters, whole milk. Casseroles can be a good choice, especially those found in older cookbooks published before today's low-fat craze.
- Don't serve foods that are too hot.
- If big meals just aren't consumed, break them up into snacks served at intervals (for example, eggs at breakfast, toast an hour or two later, a smoothie still later).
- Look into Meals on Wheels or other programs to deliver a hot meal each day if, for example, an elderly spouse is the primary caregiver.
2. Eats too much
- Forgets having eaten (even when he just left the table minutes earlier).
- Loses the ability to register the sensation of fullness.
What to do
- Serve food restaurant style (brought to the table all on one plate) rather than family style (with serving dishes on the table), which invites second and third helpings.
- If the person is an all-day snacker, make the available snacks low-calorie and filling, such as popcorn, apple slices, raw vegetables with yogurt dip (make sure choking isn't a hazard).
- Provide the person with plenty of activities to engage in to distract him between meals, since overeating may fill the vacuum of not having anything to do.
- Store snacks out of sight and out of reach, so the person has to ask for them rather than help himself.
- Don't deny the person food that you're eating yourself; instead, limit portions.
- Reassess any of your own habits that might be encouraging the person with dementia to overeat (such as mindless eating while watching TV), given that he has less self-control.
3. Doesn't drink enough liquid (dehydration)
- Loses the awareness of being thirsty.
- Simply forgets to drink during the day or with meals.
- Purposely doesn't drink because using the bathroom afterward is a physical challenge (either to use the commode or to get there in time, or both) or is something the person doesn't want to have to do in public.
What to do
- Offer liquids throughout the day; don't wait for the person to ask.
- Don't just hand over a glass; stand by and make sure the drink is actually sipped.
- Vary the types of beverages offered: water, juice, milk, hot chocolate, cider. Even coffee, tea, and soda are okay in moderation (about a cup a day) if the person prefers them. The latest thinking is that a cup or two a day doesn't pose a diuretic effect that would lead to dehydration. For someone not consuming enough liquids, liquids in any form are probably beneficial.
- Do, however, curb caffeinated beverages if fear of getting to the bathroom on time is an issue, as caffeinated drinks can cause frequent urination.
- Issue mild reminders during the meal: "Have a sip of water . . . try the iced tea."
- Leave athletic water bottles around the house or carry them around during the day. However, many older people aren't in the habit of drinking this way, so if it doesn't work, don't press the point.
- Serve fruit, which contains a lot of water, especially watermelon, melon, and citrus.
- Be sure you know the symptoms of dehydration: increased confusion or lethargy, complaints of headache, dry skin or mouth, feeling warm to the touch. Call the doctor, who may recommend a rehydration solution (such as Pedialyte). If you can't rehydrate the person by getting him to take liquids, and you don't see a change in symptoms, he may need IV (intravenous) hydration.
- Know that diarrhea and vomiting increase the risk of dehydration, so monitor the person especially closely when he's ill, and notify the doctor if you suspect dehydration.
4. Messy eating
The person may have:
- Lack of fine-motor control.
- Lack of attentiveness.
- Decreased interest in self-care and hygiene.
- Any combination of the above.
What to do
- Lower expectations and look the other way as much as you can. Spilled food can always be cleaned up.
- Use a vinyl tablecloth, which is easily wiped clean, or paper placemats that can be discarded.
- Place a napkin in the person's lap before serving food. (It might not stay there, but it's a start.)
- Cut up foods before serving.
- Serve fewer "risky" foods, such as sauces and condiments (mustard, ketchup, mayo). Preseason food before bringing it to the table.
- If manipulating utensils is difficult, switch to a "spork," a combination spoon-fork often sold in camping stores. Spoons with thick handles are also easier to hold.
- Serve finger foods that eliminate the need to use a utensil, such as fried chicken, chicken strips, pizza cut into bite-sized pieces, fish sticks, sandwiches. Cook eggs omelet-style and cut them into strips or squares that can be picked up.
- At first, offer finger-food meals to everyone at the table, so the person is less apt to feel infantile.
- Serve soup in a mug, not a bowl, and let it cool somewhat first.
- Use unbreakable dishes or heavy ironstone that's less likely to slide around.
- Choose plastic cups over glass ones.
- Serve only one or two foods at a time.
- Serve liquids in a cup with a spout (available in some hospital-supply stores), or pour only a small amount at a time into a small cup.
- If you must point out a mistake (mustard smeared on the cheek), sound casual and surprised ("Oh, that mustard is so messy, let me help you get it off your cheek") rather than shaming or blaming.
- Wash stained clothes at night so they're not worn repeatedly (a common behavior among people with Alzheimer's).
5. Goes on food jags
- The person finds that familiar favorites are comfort foods, and anxiety may make these seem preferable.
What to do
- Indulge food preferences as much as possible, provided the overall diet is reasonably balanced. It's okay to serve the same entrée day after day. (You can always cook something else for yourself.)
- Serve the same food more than once in a day if it's requested.
- Ask the doctor about adding vitamins if the diet seems unbalanced.
- Consider preparing the food in different formats: A hot chicken breast might be refused, for example, while chicken soup or chicken salad might be eaten without complaint.
- Try to serve old favorites from the person's childhood or prime of life; these are often still remembered and preferred.
6. Doesn't swallow, chokes
- Finds it physically difficult to swallow (this is called dysphagia).
- Forgets to chew.
- Consumes food too rapidly.
What to do
- Avoid hard foods: popcorn, nuts, hard candy, hard raw vegetables (such as carrots), hot dogs (unless finely diced), grapes, apples.
- Avoid foods that require a lot of chewing: celery, steak, chips.
- Avoid sticky foods such as peanut butter.
- Mash up foods or puree them in a blender or baby-food grinder; finely dice meat and cheese.
- Choose nonsolids, such as puddings, gelatins, applesauce, small-curd cottage cheese.
- Try nutritional supplement drinks (such as Ensure).
- Be sure liquids aren't too thin; they may be drunk too quickly, causing a choking hazard.
- Choose thicker soups, purees, and smoothies, which are easiest for seniors with chewing and swallowing problems.
7. Self-feeding has become impossible
In addition to the suggestions above:
- Be sure the person is sitting upright.
- Alternate solids with sips of liquids.
- Make foods more liquid as you feed -- for example, add extra milk to mashed potatoes.
- Gently coach the person through feedings: "Okay, open your mouth . . . now close . . . now chew . . . swallow. . . ."
- Try touching the person's chin or cheek as a gentle way to stimulate chewing.