How to handle common challenges Anna was a delightful lady who everyone quickly fell in love with, myself included. Like many other residents with dementia, Anna spent her days wandering around the facility, visiting and charming everyone with warm smiles, conversation, and her joy of life. At mealtimes, she was distracted and had a hard time sitting still long enough to finish a meal. Because she was walking constantly, Anna was always hungry. She would come to me and say, "Do you know where I can get something to eat? I haven't had a thing to eat all day," even though I knew she always ate well. Somehow Anna knew I would provide her with compassion, care and, best of all, food!
Residents with dementia may suffer from anorexia, undernutrition, and involuntary weight loss. In fact, approximately 90% of all patients with Alzheimer's disease lose weight.1 Studies indicate that unintentional weight loss may increase mortality, reduce resistance to infections, and increase risk of pressure ulcers.2 Residents with advanced stages of dementia also are at risk for malnutrition, dehydration, and dysphagia. Good nutritional care can help to prevent these serious complications and others, such as poor wound healing.
Good eating habits may help prevent complications, prolong independence, and improve quality of life. But facilities must first have good preventive systems in place: Effective interdisciplinary communication systems to share important information, effective weight-tracking systems to identify significant changes, and efficient methods of tracking food and fluid intake are essential. Moreover, nutrition screening tools for early identification and intervention help to prevent problems and tailor interventions for each individual.
Mealtime is one of the most important areas of focus for a positive nutritional impact, and the dining atmosphere can have a major influence on how well a resident with dementia eats. Therefore, limit distractions by removing items from the table and dining area that might distract the resident from eating. Minimal noise, calming classical music, colorful dishware, and few interruptions have been shown to improve food intake at mealtimes.
Strategic seating. Concentrate on appropriate and strategic seating to meet each resident's needs. Family-style seating may be good for one resident, but another may benefit from being in a smaller dining area with fewer people or even one-on-one dining with staff. Provide a regular routine: Present meals at the same time and in the same place each day, with a variety of favorite foods presented appetizingly.
Encouraging independence. Encourage independent eating through the use of adaptive feeding devices, finger foods, verbal or physical cueing, hand-over-hand assistance, and proper positioning for eating. Supervise, monitor, and redirect as needed, providing gentle reminders to eat.
Adequate staffing. Eating assistance is needed for residents who lose the ability to use eating utensils, have difficulty focusing on eating, or are unable to feed themselves. Ensure adequate staffing at mealtimes to assist those who need help. Take an "all hands on deck" approach to dining services-involve all department heads and office staff in helping pass trays, opening packages, cutting foods, and pouring beverages. This will free up nursing assistants to help residents with their needs. Staff must be alert to warning signs of resident malnutrition and dehydration, such as leaving >25% of food uneaten, having difficulty chewing/swallowing, refusing substitutions, hiding food instead of eating it, and/or wandering away before finishing the meal.3 Use the information CMS offers on its Web site for nutrition and hydration, www.cms.gov/partnerships/tools/materials/nutrition, as a good basis for training. Make sure staff understands that they should pass on any concerns to a supervisor for referral to the dietetics professional and care team. Finally, offer food replacements for uneaten foods (offer food first, supplements last). And most importantly, allow adequate time to eat.
Creative Solutions for Specific Problems
Sundowner syndrome. This occurs when a resident is more disoriented and distracted after the sun goes down. This may interfere with food intake during dinnertime and the bedtime snack. With respect to nutrition, the Alzheimer's Association makes these suggestions for residents with sundowner syndrome:
- Decrease caffeine (coffee, tea, chocolate, colas, etc.) or restrict to early morning hours to decrease agitation and sleeplessness.
- Offer an early dinner or a late-afternoon snack to encourage better food intake.4
Weight loss and malnutrition. Studies indicate that residents with Alzheimer's disease are more likely to lose weight compared with control groups.5 This may be caused in part by increased energy requirements as a result of increased activity (walking, pacing, or agitation). Couple this with forgetting to eat, forgetting how to eat, or being distracted from eating, and the result is a dangerous combination for health. Prevent unintentional weight loss by identifying residents at risk and intervening appropriately. Some suggestions: